International Maritime Health Association

www.intmarhealth.pl nr ISSN 1641–9251 ISSN nr

Health Maritime Association International 2020, Vol. 71, No. 1 No. 71, Vol. 2020, Official scientific forum of the: Official scientific forum Medical Journals Links, Medline, Medical Journals Links, Medline, Ulrich's Periodicals Directory, WorldCat Directory, Ulrich's Periodicals Polish Medical Bibliography, Scopus, SJR, Medical Bibliography, Polish Ministry of Science and Higher Education, Ministry of Science and Higher Education, ESCI, FMJ, Google Scholar, Index Copernicus, Copernicus, Index Google Scholar, ESCI, FMJ, Indexed/abstracted in: CrossRef, DOAJ, EBSCO, EBSCO, Indexed/abstracted DOAJ, in: CrossRef,

International Maritime Health, 2020, Vol. 71, No. 1

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TROPICAL MEDICINE TROPICAL article Review Krzysztof Korzeniewski ...... in travelers diseases Eye Safety behaviour and healthy diving: a qualitative qualitative diving: a healthy and behaviour Safety study fishermen diverse in the traditional Original article Kusnanto Kusnanto, La Rakhmat Wabula, Bambang Purwanto, Hidayat Arifin, Yulia Kurniawati MEDICINE IN MARITIME DEVELOPMENT article Review Baygi, Olaf Chresten Jensen, Agnes Flores, Fereshteh Despena Andrioti Bygvraa, George Charalambous of citations of maritime Follow-up injuryepidemiological studies...... HYPERBARIC MEDICINE Original article Richard Pougnet, Laurence Pougnet, Jean-Dominique Dewitte, Brice Loddé, David Lucas of unfitness permanent and Temporary Brest divers. occupational Cohort 2002–2019 Network National French from the Vigilance Disease Occupational for ...... (RNV3P) Prevention and Case report Sikka, Nicholas Page, Keith S. Boniface, Neal Asi Peretz, Hamid Shokoohi evacuation medical emergency ship A cruise findings ultrasound handheld by triggered tele-ultrasound by directed and MEDICINE MARITIME/OCCUPATIONAL Original article Anja Leppin Solveig Boeggild Dohrmann, Kimmo Herttua, work psychological and physical Is in stress fatigue with associated ...... ferryDanish employees? ship MARITIME MEDICINE EDUCATION 9 5 1 4 10 34 20 28 12 ...... CONTENTS

...... "International Maritime Health" is indexed at: CrossRef, DOAJ, EBSCO, ESCI, FMJ, Google Scholar, Index Copernicus, Medical Journals Links, Medline, "International Maritime Health" is indexed at: CrossRef, DOAJ, EBSCO, ESCI, FMJ, Google Scholar, Directory, WorldCat. Ministry of Science and Higher Education, Polish Medical Bibliography, Scopus, SJR, Ulrich's Periodicals the younger generation — implications implications — generation the younger merchant and fleet in the Navy prevention for Vsevolod Rozanov Mentalin problems suicide and health Costas Tsiamis, Georgia Vrioni, Athanassios Tsakris of diving safety historicLessons from a example ... sponge divers of Greek the case violation: rules Review articles Review Field study of anthropomorphic and muscle Field study and of anthropomorphic performance changes skippers elite among ...... race transoceanic a following Pierre Lafère, Yann Gatzoff, François Guerrero, Steven Provyn, Costantino Balestra Suicide, fatal injuries and drowning among among fatalSuicide, drowning and injuries Bermuda Kingdom and of United the crews ships registeredpassenger and cruise 2018...... to from 1976 Original articles E. Roberts Tim Carter, Ann John, John G. Williams, Stephen MARITIME MEDICINE Eilif Dahl ships. on cruise ultrasound Medical observation. citizens on Thai EDITORIAL Sora Yasri, Viroj Wiwanitkit of cruise: guestscrews and COVID-19, Eilif Dahl on outbreak (Covid-19) Coronavirus ...... ship Diamond Princess the cruise Coronavirus Disease 2019 as a challenge for a challengeas for 2019 Disease Coronavirus ...... medicine maritime ...... from the Editor Letter Katarzyna Sikorska EDITORIAL ANNOUNCEMENTS IMH Editorial Board INFORMATION FOR AUTHORS

The International Maritime Health will publish original papers on medical and health problems of seafarers, fishermen, INTERNATIONAL MARITIME HEALTH divers, dockers, shipyard workers and other maritime workers, as well as papers on tropical medicine, travel medicine, Former: Bulletin of the Institute of Maritime and Tropical Medicine in Gdynia, issued since 1949 epidemiology, and other related topics. Owner: International Maritime Health Foundation Typical length of such a paper would be 2000–4000 words, not including tables, figures and references. Its construc- The international multidisciplinary journal devoted to research and practice in the field of: maritime medicine, travel and tropical medicine, tion should follow the usual pattern: abstract (structured abstract of no more than 300 words); key words; introduction; hyperbaric and underwater medicine, sea-rescue, port hygienic and sanitary problems, maritime psychology. participants; materials; methods; results; discussion; and conclusions/key messages. Supported financially by: Case Reports will also be accepted, particularly of work-related diseases and accidents among maritime workers. All papers will be peer-reviewed. The comments made by the reviewers will be sent to authors, and their criticism and proposed amendments should be taken into consideration by authors submitting revised texts. Review articles on specific topics, exposures, preventive interventions, and on the national maritime health services will also be considered for publication. Their length will be from 1000 to 4000 words, including tables, figures and references.

NORWEGIAN CENTRE FOR Letters to the Editor discussing recently published articles, reporting research projects or informing about workshops MARITIME AND DIVING MEDICINE will be accepted; they should not exceed 500 words of text and 5 references. Polish Society of Maritime, HELSE BERGEN, Norwegian Centre for Norwegian Association International Maritime There also will be the section Chronicle, in which brief reports will be published on the international symposia and Tropical and Travel Medicine, Haukeland University Maritime and Diving Medicine, of Maritime Medicine, Health Association, national meetings on maritime medicine and health, on tropical parasitology and epidemiology, on travel medicine and Gdynia, Poland Hospital, Bergen, Norway Bergen, Norway Bergen, Norway Antwerp, Belgium other subjects related to the health of seafarers and other maritime workers. Information will also be given on training activities in this field, and on international collaborative projects related to the above subjects. Editor-in-Chief All articles should be submitted to IMH electronically online at www.intmarhealth.pl where detailed Maria Jeżewska instruction regarding submission process will be provided. Medical University of Gdańsk, Institute of Maritime and Tropical Medicine, Gdynia, Poland Only English texts will be accepted. (http://www.immt.gdynia.pl/) Manuscripts should be typed in double line spacing on numbered pages and conform to the usual requirements (Ref.: See our website for information on sending manuscript, aims, scope, instructions for authors (reviewers), editorial board members, International Committee on Medical Journals Editors. 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Legal note: http://czasopisma.viamedica.pl/IMH/about/legalNote For full information for authors refer to the web page: www.intmarhealth.pl. "International Maritime Health" is indexed at: CrossRef, DOAJ (Directory of Open Access Journals), EBSCO, ESCI (Emerging Sources Citation Index), FMJ, Google Scholar, Index Copernicus, Medical Journals Links, Medline, Ministry of Science and Higher Education, Polish Medical Bibliography, Scopus, SJR, Ulrich's Periodicals Directory, WorldCat. Position in Index Copernicus ranking system is available at: www.indexcopernicus.com. Copyright © 2020 Polish Society of Maritime Tropical and Travel Medicine Printed in the Republic of Poland ISSN: 1641–9251 EDITOR-IN-CHIEF: Maria Jeżewska Medical University of Gdańsk, Institute of Maritime and Tropical Medicine, 9B Powstania Styczniowego street, 81–519 Gdynia, Poland, e-mail: [email protected], tel: (+48) 601 67 65 33, fax: (+48 58) 622 33 54 DEPUTY EDITOR-IN-CHIEF: Eilif Dahl NCMDM, Haukeland University Hospital, Bergen, Norway e-mail: [email protected] Stephen E. Roberts School of Medicine Swansea University, United Kingdom e-mail: [email protected] HONORARY EDITOR: Statistical editor: Bogdan Jaremin Paweł Zagożdżon e-mail: [email protected] Department of Hygiene and Epidemiology secretary of the editorial board: Medical University of Gdańsk, Poland Leszek Mayer e-mail: [email protected] e-mail: [email protected] Language editor PUBLISHER EDITOR: Tim Carter Joanna Niezgoda NCMDM, Haukeland University Hospital, Via Medica, Gdańsk, Poland Bergen, Norway e-mail: [email protected] e-mail: [email protected]

EDITORIAL BOARD: Hyperbaric and diving medicine Epidemiology, travel and tropical medicine Marit Grönning Krzysztof Korzeniewski Department of Occupational Medicine, Department of Epidemiology and Tropical Medicine Haukeland University Hospital, Bergen, Norway Military Institute of Medicine, Warsaw, Poland e-mail: [email protected] e-mail: [email protected] Telemedicine, maritime medicine Maritime and travel medicine Alf Magne Horneland Nebojša Nikolić NCMDM, Haukeland University Hospital, Bergen, Norway Faculty of Medicina, University of Rijeka, Croatia e-mail: [email protected] e-mail: [email protected] Francesco Amenta Cardiology, maritime emergencies and accidents CIRM Rome, University of Camerino, Italy Marcus Oldenburg e-mail: [email protected] Department of Maritime Medicine, Institute Epidemiology and occupational medicine of Occupational and Maritime Medicine (ZfAM) Olaf Chresten Jensen University of Hamburg, Germany Centre of Maritime Health and Society, e-mail: [email protected] University of Southern Denmark, Esbjerg, Denmark e-mail: [email protected] Mental health and health promotion Vsevolod Rozanov Jorgen Riis Jepsen Odessa National Mechnikov University, Odessa, Ukraine Centre of Maritime Health and Society, University of Southern Denmark, Esbjerg, Denmark e-mail: [email protected] e-mail: [email protected] Psychology and safety at work Naval medicine, public health Andy Smith Jon Magnus Haga Centre for Occupational and Health Psychology NCMDM, Haukeland University Hospital, Bergen, Norway Cardiff University, United Kingdom e-mail: [email protected] e-mail: [email protected] EDITORIAL ADVISORY BOARD: Gregory Chan Chung Tsing Marcin Renke National University of Singapore, Singapore Medical University of Gdańsk, Poland e-mail: [email protected] e-mail: [email protected] Ilona Denisenko Giovanna Ricci IMH Board of Directors, Russian Federation University of Camerino, Italy e-mail: [email protected] e-mail: [email protected] Jordi Desola Przemysław Rutkowski CRIS-UTH, University of Barcelona, Spain Department of Nephrology, Transplantology e-mail: [email protected], [email protected] and Internal Diseases, MUG, Poland Lucero Prisno Don Eliseo III e-mail: [email protected] University of Liverpool, UK Maria Luisa Sanchez e-mail: [email protected] K Line Clinic, Manila, Philippines Karl Faesecke e-mail: [email protected] Hamburg Hyperbaric Center, Germany Bernd Fred Schepers e-mail: [email protected] German Maritime Health Association Christos Hadjichristodoulou e-mail: [email protected] University of Thessaly, Larissa, Greece Klaus Seidenstuecker e-mail: [email protected] Chairman German Maritime Health Association Henrik Lyngbeck Hansen e-mail: [email protected] CMHS University of Southern Denmark, Denmark e-mail: [email protected] Suzanne Louise Stannard NCMDM, Haukeland University Hospital, Bergen, Norway Suresh N. Idnani e-mail: [email protected] IMHA, ICSW, Goa, India e-mail: [email protected] Robert Steffen ISPM, University of Zurich, Switzerland Dominique Jegaden e-mail: [email protected] FSMH, Brest University, France e-mail: [email protected] Agnar Ström Tveten NCMDM, Radio Medico Norway Piotr Kajfasz e-mail: [email protected] Medical University of Warsaw, Poland e-mail: [email protected] Einar Thorsen Department Occupational Medicine, Jacek Kot Haukeland University Hospital, Bergen, Norway IMTM MUG, Gdynia, Poland e-mail: [email protected] e-mail: [email protected] Arne Johan Ulven Andrzej Kotłowski NCMDM, Haukeland University Hospital, Bergen, Norway IMTM MUG, Gdynia, Poland e-mail: [email protected] e-mail: [email protected] Donald A. Velasco Raymond Lucas University of the Immaculate Conception, George Washington, University Washington DC, USA e-mail: [email protected] Davao City, Philippines e-mail: [email protected] Alessandro Marroni DAN Europe, Italy/Malta Rob Verbist e-mail: [email protected] ICSW, Antwerp, Belgium e-mail: [email protected] Bente Elisabeth Moen University of Bergen, Norway Karin Westlund e-mail: [email protected] Sahlgrenska University Hospital Gothenburg, Sweden e-mail: [email protected] Wacław Leszek Nahorski Medical University of Gdańsk, Poland Stephen Williams e-mail: [email protected] Institute of Cruise Ship Medicine, Miami Beach, USA e-mail: [email protected] Ralph Nilsson Sahlgrenska University Goteborg, Sweden Piotr Zaborowski e-mail: [email protected] W M Medical University, Olsztyn, Poland e-mail: [email protected] Romuald Olszański Military Institute of Medicine, Warsaw, Poland e-mail: [email protected] CONTENTS

EDITORIAL ANNOUNCEMENTS Case report

IMH Editorial Board Keith S. Boniface, Neal Sikka, Nicholas Page, Asi Peretz, Hamid Shokoohi Letter from the Editor...... 1 A cruise ship emergency medical evacuation Katarzyna Sikorska triggered by handheld ultrasound findings and directed by tele-ultrasound...... 42 Coronavirus Disease 2019 as a challenge for maritime medicine...... 4 MARITIME/OCCUPATIONAL MEDICINE Eilif Dahl Original article

Coronavirus (Covid-19) outbreak on Solveig Boeggild Dohrmann, Kimmo Herttua, Anja Leppin the cruise ship Diamond Princess...... 5 Is physical and psychological work Sora Yasri, Viroj Wiwanitkit stress associated with fatigue in COVID-19, guests and crews of cruise: Danish ferry ship employees?...... 46 observation on Thai citizens...... 9 MARITIME MEDICINE EDUCATION EDITORIAL Original article Kusnanto Kusnanto, La Rakhmat Wabula, Eilif Dahl Bambang Purwanto, Hidayat Arifin, Yulia Kurniawati Medical ultrasound on cruise ships...... 10 Safety behaviour and healthy diving: a qualitative study in the traditional diverse fishermen...... 56 MARITIME MEDICINE Original articles DEVELOPMENT IN MARITIME MEDICINE Review article Tim Carter, Ann John, John G. Williams, Stephen E. Roberts Olaf Chresten Jensen, Agnes Flores, Fereshteh Baygi, Suicide, fatal injuries and drowning among Despena Andrioti Bygvraa, George Charalambous the crews of United Kingdom and Bermuda registered cruise and passenger ships Follow-up of citations of maritime from 1976 to 2018...... 12 epidemiological injury studies...... 62 Pierre Lafère, Yann Gatzoff, François Guerrero, HYPERBARIC MEDICINE Steven Provyn, Costantino Balestra Original article Field study of anthropomorphic and muscle performance changes among elite skippers Richard Pougnet, Laurence Pougnet, following a transoceanic race...... 20 Jean-Dominique Dewitte, Brice Loddé, David Lucas Temporary and permanent unfitness of Review articles occupational divers. Brest Cohort 2002–2019 from the French National Network Costas Tsiamis, Georgia Vrioni, Athanassios Tsakris for Occupational Disease Vigilance and Prevention (RNV3P)...... 71 Lessons from a historic example of diving safety rules violation: the case of Greek sponge divers... 28 TROPICAL MEDICINE Vsevolod Rozanov Review article Mental health problems and suicide in Krzysztof Korzeniewski the younger generation — implications for prevention in the Navy and merchant fleet...... 34 Eye diseases in travelers...... 78

Letter from the Editor

Dear Readers, Dear Colleagues,

Coronavirus disease (COVID-19) outbreak is a fact. In March 2020 World Health Organization (WHO) made the assessment that Covid-19 is characterized as a pandemic. The situation is dynamic. All the world, all medical authorities are focused on fighting this disease. It is the greatest challenge at the moment. The most important problems are: preventing the spread of the disease, medical treatment of infected patients, vaccine discovery. But also for people who require mental and psychosocial well-being support is especially significant.

The sudden global emergence of Covid-19 illness is of great interest for maritime health as well. Therefore, we publish three Editorial Announcements: ”Coronavirus Disease 2019 as a challenge for maritime medicine”, ”Coronavirus (Covid-19) outbreak on the cruise ship Diamond Princess” and ”COVID-19, guests and crews of cruise: observation on Thai citizens”.

In addition in the same issue ”International Maritime Health” publishes for your two press releases of relevance to maritime health:

—— INTERNATIONAL MARITIME ORGANIZATION (IMO) CIRCULAR LETTER NO. 4204/ADD. 1: “COVID-19 — IMPLEMENTATION AND ENFORCEMENT OF RELEVANT IMO INSTRUMENTS” (Source: http://www.imo.org/en/MediaCentre/HotTopics/ Documents/CL.4204-Add.1%20English.pdf; accessed: 3rd March 2020) This circular of 19th February 2020 issues information and guidance, based on recommendations developed by the World Health Organization (WHO), on the precautions to be taken to minimize risks to seafarers, passengers and others on board ships from the novel coronavirus (2019-nCoV).

—— CRUISE LINES INTERNATIONAL ASSOCIATION (CLIA) — “STATEMENT ON COVID-19” (Source: https://cruising.org/ news-and-research/press-room/2020/march/clia-covid-19-toolkit; accessed: 3rd March 2020) This press release of 2nd March 2020 from CLIA provides details on how the CLIA cruise line members will deal with cruise passengers and crew after 27th February 2020.

Take care of yourself, stay safe and healthy at this time!

IMH Editorial Board

www.intmarhealth.pl 1 Int Marit Health 2020; 71, 1: xx–3

IMO — INTERNATIONAL MARITIME ORGANIZATION

4 ALBERT EMBANKMENT LONDON SE1 7SR Telephone: +44 (0)20 7735 7611 Fax: +44 (0)20 7587 3210

Circular Letter No.4204/Add.1 19 February 2020

To: All IMO Member States United Nations and specialized agencies

Intergovernmental organizations Non-governmental organizations in consultative status with IMO

Subject: COVID-19 — Implementation and enforcement of relevant IMO instruments

The Secretary-General informs that he has received reports regarding the impacts on the shipping industry resulting from the sudden and rapid outbreak of the COVID-19 coronavirus. In response to this situation, the Secretary-General has issued guidance through Circular Letter No. 4204.

Flag State authorities, port State authorities and control regimes, companies and shipmasters should cooperate, in the current context of the outbreak, to ensure that, where appropriate, passengers can be embarked and disembarked, cargo operations can occur, ships can enter and depart shipyards for repair and survey, stores and supplies can be loaded, certificates can be issued and crews can be exchanged.

The principles of avoiding unnecessary restrictions or delay on port entry to ships, persons and property on board are also embodied in articles I and V and section 6 of the annex of the FAL Convention.

Several IMO instruments contain provisions that may be relevant to the impact on shipping caused by the outbreak of COVID-19. These include, but are not limited to: • the International Convention for the Safety of Life at Sea, 1974; • the International Convention for the Prevention of Pollution from Ships, 1973; • the International Convention for the Control and Management of Ships’ Ballast Water and Sediments, 2004; • the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978; and • resolution A.1119(30), Procedures for port State control, 2017.

In addition, the Secretariat has received the following communication from the International Labour Organization (ILO): “In the context of the evolving coronavirus outbreak, the effective protection of the health and safety of seafarers should be a priority. Under the International Labour Organization’s (ILO) Maritime Labour Convention, 2006, flag States must ensure that all seafarers on ships flying their flag are covered by adequate measures for the protection of their health and that they have access to prompt and adequate medical care whilst working on board. The Convention also requires port States to ensure that seafarers on board ships in their territory who are in need of immediate medical care are given access to medical facilities on shore.”

COVID-19 is a severe public health challenge that requires understanding and close cooperation among all Member States to overcome challenges related to the implementation and enforcement of the relevant IMO instruments.

The Organization will continue to closely monitor the situation and the Secretary-General will provide additional information as appropriate and will bring these matters to the attention of the relevant organs of the Organization, in particular the Maritime Safety Committee, the Marine Environment Protection Committee, the Facilitation Committee and the Legal Committee.

2 www.intmarhealth.pl Pierre Lafère et al., Differential effect of offshore race on limbs

PRESS RELEASE | MARCH 02, 2020 Cruise Lines International Association (CLIA) Statement on COVID-19

WASHINGTON, DC (1 MAR 2020) — Cruise Lines International Association (CLIA), the leading voice of the global cruise industry, issued today the following statement in response to recent developments concerning COVID-19 and its impact on the global cruise industry.

“The health and safety of cruise passengers and crew is and remains the number one priority of CLIA and its member lines, which make up over 90% of ocean-going cruise capacity worldwide.

Given the evolving nature of the ongoing COVID-19 — and based upon prevailing guidance from global health authorities, including the World Health Organization (WHO) — CLIA Members have adopted the following enhanced protocols for ocean-going guests and crew who have recently traveled from or through Iran, South Korea and China, including Hong Kong and Macau. These enhanced policies, which are in effect as of 27 February 2020, build upon those which were first implemented on 31 January 2020 and focus on conservative measures, as the situation evolves, to appropriately and effectively screen every guest and crewmember on every ship prior to boarding.

• CLIA Members are to deny boarding to all persons who have traveled from, visited or transited via airports in Iran, South Korea and China, including Hong Kong and Macau, within 14 days before embarkation.

• CLIA Members are to deny boarding to all persons who, within 14 days before embarkation, have had close contact with, or helped care for, anyone suspected or diagnosed as having COVID-19, or who is currently subject to health monitoring for possible exposure to COVID-19.

• CLIA Members are to conduct preboarding screening necessary to effectuate these prevention measures. Enhanced screening and initial medical support are to be provided, as needed, to any persons exhibiting symptoms of suspected COVID-19.

In coordination with cruise lines, medical experts and regulators around the world, CLIA and its member lines will continue to closely monitor for new developments related to the coronavirus and will modify these policies as necessary with the utmost consideration for the health and safety of passengers and crew. With strict measures in place, as guided by national and international health authorities, CLIA and its member lines do not believe restrictions on the movement of ships are justified.

Importantly, the cruise industry is one of the most well-equipped and experienced when it comes to managing and monitoring health conditions of those onboard, with outbreak prevention and response measures in place year-round. Furthermore, ships must be fitted with onboard medical facilities, with shipboard medical professionals available around the clock, 24/7, to provide initial medical care in the event of illness and help prevent disease transmission.”

Coronavirus Disease 2019 as a challenge for maritime medicine

Katarzyna Sikorska

Department of Tropical and Parasitic Diseases, Institute of Maritime and Tropical Medicine, Faculty of Health Sciences with Institute of Maritime and Tropical Medicine, Medical University of Gdansk, Gdynia, Poland

On 11 March 2020 World Health Organization (WHO) mune response, risk of reinfections are not fully explained, ”made the assessment that Coronavirus Disease 2019 becoming a scientific challenge. (COVID-19) can be characterised as a pandemic”. Six weeks At present SARS-CoV-2, due to its dynamic spread all earlier, on 30 January 2020, the outbreak caused by a novel over the world, appears to be a significant threat to public coronavirus was declared a Public Health Emergency of health in all spaces, especially in international transport, International Concern [1]. including maritime conveyance. The problem of dealing with The history of this new threat to human population is a suspected case of COVID-19 does not bypass board ships, very short with rapid evolution in his perception and unprec- not only cruise ships. Dramatic fate of tourists imprisoned edented decisions to limit global communication that have on luxury cruise ships because of spread of SARS-CoV-2 never been seen before in the era of technical civilisation. infection on board was an unexpected and shocking con- The first cases of pneumonia of unknown origin which sequence of rapid, inauspicious changes of epidemiological was linked to a seafood and wet animal wholesale market situation on mainland. It has highlighted the need to train in Wuhan, China were reported on 31 December 2019 [2]. personnel working at sea in area of epidemiology, under- In mid-March 2020 there are 133,860 cases worldwide in standing of psychosocial conditions of epidemic and the 122 countries with 4967 deaths in all continents excluding basic principles of infectious disease prevention. It turned Antarctica. The rate of increase in the number of new cases out necessary to prepare documents organising the rules and deaths outside of China does not decrease [3]. The of conduct in the event of a new epidemic threat on board lack of both: effective antiviral therapy and the possibility ship. Early detection, prevention, and control of COVID-19 on of active immunisation (vaccine) means that the basic tool ships appeared to be important tasks both to protect the sea to fight the epidemic is an old weapon, which was used workers’ and travellers’ health and to avoid transmission of in the past against highly contagious infectious diseases: the virus by disembarking passengers and crew members quarantine and isolation. Fortunately, now it is enhanced who are suspected of having COVID-19 [5, 6]. by the possibility of early, effective detection of infection using methods of molecular biology. REFERENCES On 12 February 2020 a new strain of zoonotic coronavi- 1. www.who.int/emergencies/diseases/novel-coronavirus-2019 (ac- rus which has not been previously identified in humans was cess: 13 March 2020). 2. Zhu Na, Zhang D, Wang W, et al. China Novel Coronavirus Investi- named severe acute respiratory syndrome coronavirus 2 gating and Research Team. A Novel Coronavirus from Patients with (SARS-CoV-2). COVID-19 is a name of a new disease asso- Pneumonia in China, 2019. N Engl J Med. 2020; 382(8): 727–733, ciated with this virus. Human-to-human transmission via doi: 10.1056/NEJMoa2001017, indexed in Pubmed: 31978945. respiratory droplet or direct contact with infected subjects 3. www.ecdc.europa.eu/en/novel-coronavirus (access: 13 March 2020). 4. Guan WJ, Ni ZY, Hu Yu, et al. China Medical Treatment Expert Group was confirmed and also a clinical picture from mild disease for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 of respiratory tract to severe pneumonia and life threatening in China. N Engl J Med. 2020 [Epub ahead of print], doi: 10.1056/ respiratory failure has been extensively described. Mean NEJMoa2002032, indexed in Pubmed: 32109013. mortality is estimated to be 3.5% with rapid increase in 5. Operational consideration for managing COVID-19 cases and outbre- ~ aks on board ships. Interim guidance February 2020. World Health older patients reaching 15% in the group of > 80 years and Organisation/date of access: 13 March 2020. with underlying medical conditions [4]. Still many issues 6. www.cdc.gov/quarantine/maritime/recommendations-for-ships on persistence of contagiousness, type and efficacy of im- (access: 13 March 2020).

Katarzyna Sikorska, Department of Tropical and Parasitic Diseases, Institute of Maritime and Tropical Medicine, Faculty of Health Sciences with Institute of Maritime * and Tropical Medicine, Medical University of Gdansk, ul. Powstania Styczniowego 9b, 81–519 Gdynia, Poland, e-mail: [email protected]

4 www.intmarhealth.pl Int Marit Health 2020; 71, 1: 5–8 10.5603/IMH.2020.0003 www.intmarhealth.pl EDITORIAL ANNOUNCEMENT Copyright © 2020 PSMTTM ISSN 1641–9251 Coronavirus (Covid-19) outbreak on the cruise ship Diamond Princess

Eilif Dahl

Department of Occupational Medicine, Norwegian Centre for Maritime and Diving Medicine, Haukeland University Hospital, Bergen, Norway

introduction to potentially contagious passengers and crew, regardless The whole world has recently been following the media of consequences for those aboard. Ships are bound by in- frenzy covering the quarantine of Diamond Princess, the ternational treaties to follow port rules and protocols, and first cruise ship that had an outbreak of coronavirus illness in this case Diamond Princess followed the instructions (Covid-19) on board. It developed soon after the occurrence of the Japanese health authorities to the letter while also of China’s Covid-19 outbreak, which — according to the working closely together with the United States (US) Centers World Health Organization (WHO) — “poses a very grave for Disease Control and Prevention (CDC) [3]. threat for the rest of the world” and should be viewed as Coronavirus virus is thought to spread mainly from per- “Public Enemy Number 1” [1]. Lasting more than 14 days, son-to-person, between people who are in close contact with the ship quarantine is unprecedented for the cruise industry, one another (within about 6 feet) through respiratory drop- and some maritime health issues of concern may be worth lets produced when an infected person breathes, coughs addressing already shortly after the interned passengers or sneezes. It may be possible to get Covid-19 by touching and crew had finally disembarked the vessel. a virus-contaminated surface or object, and transmission might also happen before people show symptoms. Most THE CRUISE VESSEL OUTBREAK Covid-19 cases have so far been mild; the overall average Diamond Princess had been on a cruise that originated mortality rate is estimated at 1–2%, but may change over in Yokohama on 20 January 2020 and included stops in time [4]. Kagoshima, Hong Kong, Vietnam, Taiwan and Okinawa Shortly after quarantine was decided for Diamond Prin- before returning to Yokohama on 3 February. A passenger, cess, some passengers developed symptoms and tested who disembarked on 25 January in Hong Kong, developed positive for Covid-19. They were hospitalised ashore while a cough on 19 January and on 1 February tested positive the rest had to remain in their cabins [2]. for SARS Coronavirus II, a novel virus causing an illness During the quarantine, the number of persons showing now internationally known as Covid-19. The Japanese gov- symptoms and testing positive for the virus increased steadi- ernment requested that Diamond Princess stay at port ly. For a time, the vessel had the largest concentration of in Yokohama, with no passengers or crew disembarking. cases outside of mainland China, where the virus is thought During 3–4 February, the health status of all passengers to have originated [4]. and crew was checked by questionnaire by quarantine Due to the nature of the ship, individual isolation of all officers, and respiratory specimens were taken from symp- those aboard was not possible. Sharing cabins was neces- tomatic passengers, crew, and their close contacts to test sary, and some crew had to perform essential extra duties for the coronavirus. On 5 February, a lab-confirmed case while passengers remained aboard. Transmission toward of Covid-19 led the Japanese Ministry of Health, Labour the end of the quarantine period occurred mostly among and Welfare, to initially quarantine Diamond Princess for crew or within passenger cabins [2]. 14 days with passengers requested to stay in their cabins. The initial quarantine period was scheduled to end on As of 5 February, there were a total of 3711 multinational 19 February. As of 20 February, over 1600 individuals have individuals (2666 passengers and 1045 crewmembers) been disembarked from the Diamond Princess. Nearly all on board [2]. disembarked individuals had observed 14-day quarantine The primary purpose of vessel quarantine has always without sharing a cabin with a confirmed case, had received been to protect the public ashore by preventing exposure a recent negative polymerase chain reaction tests, and

* Professor Emeritus Eilif Dahl, MD, MHA, PhD, Professor Dahls gate 50A, 0260 Oslo, Norway, tel: +47 95921759; e-mail: [email protected]

www.intmarhealth.pl 5 Int Marit Health 2020; 71, 1: 5–8 had passed a medical screening for symptoms (e.g. fever, global influenza epidemics. On a positive note, the risk of cough). At that time 619 cases had been confirmed (16.7% confusing influenza symptoms with those of Covid-19 may of the population on board), including 537 passengers and have been reduced in the crew population because most 82 crewmembers. A total of 3011 respiratory specimens Diamond Princess crewmembers are annually vaccinated had been tested, and 621 were positive (20.6%), including against influenza according to company policy and might double tests. Persons aboard between 70 and 89 years of already have received this season’s dose. age were the most affected. Of all confirmed cases, 318 What makes Covid-19 especially problematic for cruise (51%) were asymptomatic when the respiratory specimen ships, is an incubation time of 2–14 days — and possibly was collected (308 passengers and 10 crew) [2]. longer, and quarantine of Diamond Princess was therefore On 27 February Princess Cruises confirmed that dis- necessary for all exposed persons for that long period. embarkation of all guests aboard Diamond Princess had Anyone who developed symptoms and tested positive for been completed. Of the remaining crew, some departed Covid-19 at any time during their 14-day isolation period by foreign government charter flights, while the rest were may have been contaminated before quarantine started. taken to a local quarantine facility to complete a secondary They then had to be isolated off the ship until they tested quarantine required by the Japan Ministry of Health [5]. negative and could be declared non-contagious. And when As of 29 February, Japan’s Ministry of Health reported new patients were diagnosed, their immediate pre-isolation that 705 people from the ship had contracted the virus [2]. contacts had to be traced and quarantined as well [2]. CDC announced the same day that 44 passengers flown In addition to those who got the virus before they were back to the US had tested positive. At that time 6 people quarantined, further persons on board may test positive for who were on the ship had died in hospitals [3]. Covid-19 during or after the quarantine period if the cabin seclusion was incomplete, which can easily happen because QUARANTINE AND CONFINEMENT those in isolation have to be tested, fed and aired mainly ISSUES ABOARD by the ship’s crew. Cruise vessels are isolated communities with a high population density, crowded public rooms and living ac- CREW EXPERIENCE FROM commodation, shared sanitary facilities, and common water PREVIOUS OUTBREAKS and food supplies. Hence, infectious diseases are easi- Whether on land or at sea, managerial mistakes will ly transmitted aboard, by infected persons and through always be made at the start of an outbreak, especially when contaminated surfaces, food and water. This also makes the illness is caused by hitherto unknown pathogens. Previ- handling outbreaks on ships very difficult, in particular the ous outbreak experience helps, and most cruise vessels are quarantine of large numbers of passengers and crew. quite well prepared to handle smaller outbreak, like those Presence aboard a ship of a newly discovered virus that caused by norovirus, the most common cause of acute spreads person-to-person, and possibly via contaminated gastroenteritis outbreaks on cruise ships [7]. surfaces and asymptomatic persons, is certainly a chal- A cruise vessel the size of Diamond Princess would nor- lenge, especially when testing possibilities are limited and mally be expected to have a medical staff of 2 doctors and time-consuming, and getting test results takes days. A Thai 3 nurses. That is usually sufficient for daily routine shipboard physician suggests why early tests on fluids from noses and work, but even a small number of norovirus patients will tax throats often turns out negative: “The virus lodges deep a staff of that size to the limit, even though the average isolation in the lower windpipe and lungs, so patients will not have time for such patients is less than two days on a well-run ship. a cough or sore throat when they first develop the disease” [6]. An outbreak of viral gastroenteritis on a cruise ship, Another concern: some Covid-19 patients that seemed defined as involving more than 3% of passengers or crew cured and tested coronavirus negative, have later had [7], demands the involvement of all officers and crew and positive tests. This could be due to “reinfection” because will quickly exceed the capacity of the ship´s medical staff. of insufficient immune response to the initial infection or Outside assistance will then be essential, but is not always “bi-phasic” virus behaviour; the virus lies dormant before available — for a variety of reasons. creating new symptoms (“reactivation”). Or inconsistent However, an outbreak of a contagious disease where results might be attributed to testing discrepancies. symptomatic patients and their contacts must be isolated Adding to the challenge on board Diamond Princess for a minimum of 14 days, longer than the length of the are the facts that initial Covid-19 symptoms are similar average cruise, is truly worrying and brings a multitude to those of influenza and the common cold (fever, cough, of new challenges. The long incubation period alone will respiratory issues), and the Covid-19 outbreaks ashore drastically influence the practice of cruise ship medicine and then on board started at the height of the annual for the foreseeable future.

6 www.intmarhealth.pl Eilif Dahl, Coronavirus (Covid-19) outbreak on the cruise ship Diamond Princess

CHALLENGES DURING MEDICAL STAFF CHALLENGES THE CURRENT OUTBREAK The highest-risk group aboard for contracting Covid-19, The media focus has primarily been on the ordeal of the ship’s few doctors and nurses faced medical and mental the Diamond Princess passengers, but the controversial health burdens of their own. They must try to handle non- 2-week quarantine was even more difficult for the cruise -Covid-19 emergencies and regular medical issues of pas- ship’s 1045 crewmembers. Cruise vessels are staffed to sengers and crew as they usually do, but confined persons provide high-level service to their passengers, and the crew are not allowed to visit the Medical Facilities so consulta- is usually kept busy enough by performing their regular tions must be done in the cabin, with limited diagnostic pos- duties. During quarantine all kinds of additional services sibilities. Also, the obligatory clinical evaluation and testing had to be provided — not in public rooms but individually to of all the potentially infected persons must be done in the the passenger cabins, and crewmembers had to do extra cabins as well; just try to imagine the time and effort — and tasks, for which they in many cases had not been trained, man power — it will take to just make brief individual visits to to keep the quarantined ship running. And they had to do thousands of people in their living quarters aboard — while it all while they knew themselves to be at arguably greater ensuring that the contagion is not transferred from cabin risk of getting the illness than the passengers they were to cabin and while trying not to get contaminated yourself. serving. They had frequent, although limited, contact with All the issues addressed above meant additional work the quarantined passengers, and interacted closely and con- for the vessel’s medical staff. In such situations they must stantly with other, potentially contagious co-workers during somehow get prompt medical and other support from work and off duty, sharing rooms, toilets, and dining spaces. ashore, to be arranged through the company’s medical Thus, although effectively protecting the public ashore, headquarter ashore. The Medical Department of Princess quarantine for those aboard was flawed. Consequently, both Cruises has for many years been in the lead of providing first- passengers and crew increasingly felt helpless, anxious, rate medical care for passengers and crew and, being part and fearful, and over time various degrees of mental and of a large corporation, have the expertise and resources that physical exhaustion were common [8]. smaller cruise lines do not command. But support provided A particular quarantine challenge is that Diamond Prin- from the outside will often be from persons who, unfamiliar cess like most cruise vessels has a diverse multinational with conditions on board, will themselves require help from and multicultural passenger and crew population, with very the already overworked ship staff. For the quarantine-related different service expectations and reactions to authoritarian tasks the ship’s medical staff received unspecified assis- rules regarding behaviour. After all, people were virtually tance from outside, and as of 28 February, one quarantine incarcerated for more than 14 days; in many instances with officer who worked on the ship had contracted the virus [2]. other persons they wouldn’t usually spend so much time with in one small room on a daily basis; the lucky ones had LESSONS LEARNED? balconies, but many passengers and most of the crew had Retrospectively, it is easy to criticise how the quarantine indoor windowless cabins. was handled. Again, the primary quarantine goal for the Quarantine is a logistic nightmare for shore-side and Japanese port authorities was to protect the public ashore, ship management and for supervisors at all levels aboard. but trying to keep passengers apart from each other and They must ensure consistently safe and professional opera- from crew by retaining them in their cabins was not an ideal tion of all aspects of the vessel, 24/7, also under extraordi- solution because potentially contagious crew had to interact nary circumstances. Therefore, a primary goal and ongoing among themselves and serve the passengers to keep the ship challenge will be to keep up morale and motivate a steadily operation running. Failing to isolate the crew of the Diamond more overtaxed crew to continue not only to work but also to Princess from the beginning of the quarantine likely contrib- provide the expected “excellent cruise service”. There is fur- uted to further virus transmission to passengers and crew thermore constant pressure from the cruise company, port during the quarantine time and made it necessary to subject and health authorities, and media for continuously updated the remaining crewmembers to another full quarantine period documentation of all aspects of their actions. Moreover, ashore after all passengers had debarked [2]. unprecedented operations have to be organised: enhanced The Covid-19 quarantine might have serious adverse ef- safety and security measures, special daily housekeeping fects. There will be expert medical and psychological care of activities, mobile food and beverage services to all cabins all the involved crewmembers during on-going seclusion [5] under ‘biohazard’ conditions, daily strictly supervised walks — and hopefully also long-term follow-up at home. This will on deck for passengers with interior windowless cabins, be necessary to counteract post-traumatic stress reactions prompt and decisive handling of accidental and planned from involuntary frontline work in a dangerous environment breeches of confinement, and so on and on. — and from the subsequent quarantine ashore.

www.intmarhealth.pl 7 Int Marit Health 2020; 71, 1: 5–8

Dealing with quarantine of a foreign-flagged and -oper- ADDENDUM ated ship is difficult for a single government, and there is To watch a video where Dr. Grant Tarling, MD, MPH, Chief clearly a need for a worldwide framework to tackle future Medical Officer for Princess Cruises, explains the issues to crises. Hence, the cruise industry, governments, internation- guests aboard the Diamond Princess on 12 February 2020, al maritime organisations, and other stakeholders should please see https://www.youtube.com/watch?v=PGQZjkFg- push for global treaties to ensure that ports cannot turn 8ZM&t=55s. The published commentaries are mostly com- away ships with outbreaks but must arrange for urgent quar- plementary, while the more critical ones demonstrate clearly antine of all potentially contaminated persons not aboard how little the public at large understands of shipboard life. but ashore, as well as for urgent shore-side isolation and hospitalisation of all suspected and symptomatic patients. Conflict of interest Diamond Princess during the first months of 2020 is to be The author has no commercial, financial or other rela- considered a de facto epidemiological laboratory. Evidence tionships related to the subject of this article. He has worked gathered from its outbreak will provide important information as ship’s doctor for many cruise companies, including once for the global Covid-19 investigation and must be shared fully for Princess Cruises (Star Princess 2013). to promote future contingency plans and to improve health conditions on all cruise vessels. When (not if) further Covid-19 REFERENCES and similar outbreaks on ships occur, detailed industry plans 1. Nebehay S, Farge E. Update 3- Coronavirus emergency is “Public for worldwide cooperation regarding emergency medical staff- Enemy Number 1”. WHO via Reuter, 11 February 2020. https:// ing and assistance need to be in place. www.reuters.com/article/us-china-health-who/coronavirus-emergency-is-public-enemy-number-1-who-idUSKBN2050YV. 2. The Japanese National Institute of Infectious Diseases (NIID). Field FUTURE CRUISING Brief: Diamond Princess COVID-19 Cases. 20 Feb Update. https:// High risk of contracting a contagious illness with an in- www.niid.go.jp/niid/en/2019-ncov-e/9407-covid-dp-fe-01.html cubation time > 14 days, transmittable through contagious (Accessed 01 March 2020). asymptomatic persons and possibly via contaminated sur- 3. US Centers for Disease Control and Prevention (CDC). Coronavirus faces, will change the practice of cruise ship medicine as disease 2019. https://www.cdc.gov/coronavirus/2019-ncov/ we know it. Fear of contracting Covid-19 will prevent many index.html (Accessed 02 March 2020). 4. Virus monitor. Covid-19 coronavirus outbreak. https://www.worldo- prospective customers from booking cruises, in particular meters.info/coronavirus (Accessed 29 February 2020). itineraries that might include future endemic areas. But be- 5. Princess Cruises. Updates on Diamond Princess: Guest Disembar- fore long, a bigger passenger and prospective crewmember kation Complete + Team Member Quarantine – 27 February 2020. concern will be the risk of involuntary quarantine for weeks https://www.princess.com/news/notices_and_advisories/noti- to months aboard or/and abroad — far away from home. ces/diamond-princess-update.htm (Accessed 02 March 2020). Eventually, especially when an effective vaccine has 6. Hemachuda T. In: Probe into virus death. Bangkok Post. 2020; become available, conditions may normalize to the extent 02 March. that Covid-19 will not appear more frightening than in- 7. US Centers for Disease Control and Prevention (CDC). Vessel Sani- tation Program 2018 Operations Manual. https://www.cdc.gov/ fluenza. Then the focus will shift to maintaining normal nceh/vsp/docs/vsp_operations_manual_2018-508.pdf. shipboard life as much as possible, whilst implementing 8. Subramanian S. The Ordeal of the Diamond Princess Crew. The Diplo- standard outbreak prevention measures to reduce the risk mat, 22 February 2020. https://thediplomat.com/2020/02/the of transmission, like less touching and lots of hand washing. -ordeal-of-the-diamond-princess-crew (Accessed 01 March 2020).

8 www.intmarhealth.pl Int Marit Health 2020; 71, 1: 9 10.5603/IMH.2020.0004 www.intmarhealth.pl EDITORIAL ANNOUNCEMENT Copyright © 2020 PSMTTM ISSN 1641–9251 COVID-19, guests and crews of cruise: observation on Thai citizens

Sora Yasri1 , Viroj Wiwanitkit2, 3

1KMT Primary Care Centre, Bangkok, Thailand 2Dr DY Patil University, Pune, India (honorary professor) 3Hainan Medical University, Haikou, China (visiting professor)

COVID-19 is a new emerging infection starting from Thais (1 guest, 2 crews) got infection. The rate of infection China [1]. This new disease was imported to many countries among Thai citizens on the cruise is equal to 12% (95% such as Thailand [2]. After the firs importation to Thailand as confidence interval [CI]: 4.15–34.69%). The infection rate the first country, there are already more than 20 countries among Thai guests and crews are 50% (95% CI: 12.5–100%) with imported disease. At first, the importation of disease and 8.7% (95% CI: 2.31–32.69%), respectively. Based on is mainly by air travel. However, the new consideration this observation, the infection rate among Thai guests is is raised when there is an emerging problem of disease higher than that of Thai crews. It might reflect that the guest outbreak at international tourist cruise. The outbreak on of the tourist cruise has a higher chance than crew to get Diamond Princess, which was detected in Japan, became disease in case of outbreak of new infection. an interesting situation. Here, the authors would like to discuss on the obser- References 1. Hsia W. Emerging new coronavirus infection in Wuhan, China: vations on Thai citizens on that cruise. Based on available Situation in early 2020. Case Study Case Rep. 2020; 10(1): 8–9. data, there 2 Thai guests and 23 Thai crews. From 3700 2. Yasri S, Wiwanitkit V. Editorial: Wuhan coronavirus outbreak and people on the cruise, there were 25 Thais and 3 of those imported case. Adv Trop Med Pub Health Int. 2020; 10(1): 1–2.

* Dr. Sora Yasri, KMT Primary Care Centre, Bangkok Thailand, e-mail: [email protected]

Eilif Dahl

Department of Occupational Medicine, Norwegian Centre for Maritime and Diving Medicine, Haukeland University Hospital, Bergen, Norway

In this issue of ”International Maritime Health” Boniface two decades. The devices have become smaller and far et al. [1] report a case where an ultrasound examination easier to use, they are more portable and durable, and the performed aboard a cruise ship triggered an emergency relative cost has decreased considerably. Basic ultrasound medical evacuation of a young female crewmember. The is now part of medical education and advanced training is ship’s doctor identified an ectopic pregnancy by ultrasound done during emergency medicine and other specialisations and the diagnosis was confirmed by remote tele-medical in many countries. review of the images. The authors emphasize that point- Hence, ultrasound is now a low-cost, reliable, diagnostic of-care ultrasound examination can remove uncertainty tool that can be used on cruise ships by bedside providers from the decision to urgently evacuate, and they make with some focused basic skills, in particular when ultrasound a compelling plea for all cruise vessels to have ultrasound expert backup is available from Tele-Medical Assistance equipment and staff with skills to use it and to correctly Services (TMAS) ashore, as in the case of Boniface et al. [1]. interpret the findings. They state that medical care aboard cruise ships follow Sonography on cruise ships is not a new idea, but it has guidelines from the American College of Emergency Physi- been slow to catch on. When the then Japanese-owned cians (ACEP) and suggest to include point-of-care ultrasound Crystal Cruises brought out its first luxury vessel in 1990, in future revisions. It may not be instantly clear to interna- its Medical Facilities had an ultrasound device. It was bulky tional readers why the authors refer to a document from and not very user-friendly, and the ship’s doctors had limited a national association. or no hands-on ultrasound experience. Sonography was The reason is simple; there are no international rules therefore rarely attempted, and the images had never any and regulations dealing with the practice of cruise ship decisive influence on patient handling. medicine. International organisations, like the Internation- Curiously though, once in the early years, a passenger al Maritime Organisation (IMO), have never shown much couple presented in the Medical Facilities of Crystal Har- interest in the practice of cruise ship medicine. Maybe this mony shortly after embarkation to have the wife’s vague will change in the near future, following the intense media abdominal discomfort sorted out. When the husband, attention of the recent coronavirus (Covid-19) outbreak on a radiologist, saw the ultrasound device, he wanted to use it M/S Diamond Princess [2]. to exclude acute appendicitis. He found nothing abnormal, Let’s return to the early 1990s, when mass cruise tour- but the ship’s doctor was not convinced and — considering ism was in its infancy. Some members of ACEP had briefly the ship’s immediate itinerary — insisted on a port referral. worked on cruise ships and been appalled by the low status A few hours later the ship left for its scheduled 2-week of ship’s doctors and poorly equipped ship infirmaries. To cruise to remote Antarctica — without the couple, but with remedy that and seeing cruise ship medicine as an attrac- a very relieved medical staff aboard. Ectopic pregnancy tive alternative career path for emergency physicians, they had been diagnosed by ultrasound ashore and treated started in 1990 a Section for Cruise Ship and Maritime surgically there. Medicine within ACEP [3]. Not long after this incident the device was removed from While creating guidelines for cruise ship medicine, the Crystal Harmony, and ultrasound equipment was not even Section initially suggested that only United States (US) ordered for the company’s next two vessels. trained emergency physicians should be hired as doctors But that was long ago, and — as Boniface et al. [1] write on cruise ship since most cruise passengers were Amer- — ultrasound equipment has evolved rapidly over the past ican. ACEP had to turn that proposal down because very

* Professor Emeritus Eilif Dahl, MD, MHA, PhD, Professor Dahls gate 50A, 0260 Oslo, Norway, tel: +47 95921759; e-mail: [email protected]

10 www.intmarhealth.pl Eilif Dahl, Medical ultrasound on cruise ships few cruise ships were US registered, and most ship doc- on board less experienced ultra-sonographers to obtain and tors were non-US citizens. In 1995 ACEP published its first interpret images that can impact patient care in real-time, in “Health Care Guidelines for Cruise Ship Medical Facilities”, particular in cases when urgent evacuation may be an issue. the result of consensus among active ship’s doctors. They Structuring ultrasound training into ports during turn- were very basic, specified just a few laboratory tests, and around, as found feasible by Boniface et al. [1], may work X-ray equipment only on ships delivered after 1997 [3]. But — for some ships in some ports. It is hardly a workable they were still strongly opposed by the cruise industry that solution for the whole industry and does not meet ACEP did not want any focus on illness aboard ships and worried ultrasound standards [6]. about costs and potential liability. The challenge remains the training and certification Nevertheless, over the ensuing years it became appar- programme for a global medical staff workforce and the ent that cruise ship doctors and the industry had common over-reads, but it is just a matter of time before point-of-care goals, and for many years ACEP has collaborated with the ultrasound will be the norm on all cruise ships. Cruise Lines International Association (CLIA) to further develop and implement the Guidelines. Representing more than Conflict of interest 95% of global cruise capacity, CLIA is the world’s largest The author has no commercial, financial or other re- cruise industry trade association and focused on passenger lationships related to the subject of this article. He has satisfaction, particularly regarding service, safety, security worked as ship’s doctor and medical consultant for many and health [4]. As they are now mandatory for CLIA ocean- cruise companies. going Cruise Line Members, the ACEP Guidelines can be considered a minimum global industry standard. References In the 2019 revision of the ACEP/CLIA Guidelines, 1. Boniface KS, Sikka N, Page N, et al. A cruise ship emergency me- a comprehensive document, ultrasound equipment is not dical evacuation triggered by handheld ultrasound findings and directed by tele-ultrasound. Int Marit Health 2020; 71(1): 42–45, mentioned. Guideline 8.1. on imaging states “X-ray imaging doi: 10.5603/IMH.2020.0010. capabilities which includes one X-ray generator and one 2. Covid-19 coronavirus outbreak. https://www.worldometers.info/ processing/developing system” [3]. Hence, at this time it coronavirus/ (accessed 29 February 2020). is up to each cruise company to decide on ultrasound use. 3. American College of Emergency Physicians (ACEP). Section for Cruise Getting the necessary ultrasound equipment on board Ship Medicine. https://www.acep.org/patient-care/policy-state- all cruise ships and ensure proper training and skills of all ments/health-care-guidelines-for-cruise-ship-medical-facilities/ (accessed 15 November 2019). present and future cruise ship doctors will be a formidable 4. Cruise Lines International Association. CLIA oceangoing cruise line undertaking. Yet the German Maritime Medical Associa- policies. https://cruising.org/about-the-industry/policy-priorities/ tion, another national organisation, has issued guidelines cruise-industry-policies/Health (accessed 29 February 2020). that make ultrasound and medical staff qualified to use 5. Seidenstuecker KH, Neidhardt S. Qualification of ship doctors: it mandatory on (the few) cruise vessels registered in a German approach. Int Marit Health. 2014; 65(4): 181–186, doi: Germany [5]. 10.5603/IMH.2014.0035. 6. American College of Emergency Physicians (ACEP). Section for Whether ultrasound equipment is included in cruise Emergency Ultrasound. Ultrasound Guidelines: Emergency, Point-of- ship medicine guidelines or not, there will be an increasing care, and Clinical Ultrasound Guidelines in Medicine. https://www. number of ships that will carry it and ship’s doctors that acep.org/globalassets/uploads/uploaded-files/acep/clinical-an- will use it. Therefore maritime TMAS around the world must d-practice-management/policy-statements/ultrasound-policy- already now prepare for providing remote experts to direct 2016-complete.pdf (accessed 29 February 2020).

www.intmarhealth.pl 11 Int Marit Health 2020; 71, 1: 12–19 10.5603/IMH.2020.0006 www.intmarhealth.pl ORIGINAL ARTICLE Copyright © 2020 PSMTTM ISSN 1641–9251 Suicide, fatal injuries and drowning among the crews of United Kingdom and Bermuda registered cruise and passenger ships from 1976 to 2018

Tim Carter1, Ann John2 , John G. Williams2, Stephen E. Roberts2

1Norwegian Centre for Maritime and Diving Medicine, Haukeland University Hospital, Norway 2Medical School, Swansea University, Swansea, United Kingdom

ABSTRACT Background: Little has been reported about mortality among crews in passenger shipping. The aim of the study was to determine the detailed causes and circumstances of deaths from unnatural causes among crews employed in United Kingdom (UK) and Bermudan registered passenger shipping, their trends, how they relate to the type of passenger ship and crew rank and to discuss preventative measures. Materials and methods: A longitudinal study from 1976 to 2018, based on reviews of marine accident investigation reports, death inquiry files, cruise shipping websites and online searches. Results: One hundred and forty crew fatalities in UK (127) and Bermudan (13) passenger ships were identified: from accidents and drowning (91), suicides and disappearances at sea (38), homicide, other and unexplained causes (11). Over the 43-year study period, a reduction in mortality (per 1000 ship-years) from accidents and drowning was identified (mean annual reduction: 4.3%; 95% confidence interval: 2.1–6.5%) but no significant reduction for suicides and disappearances at sea (annual reduction: 1.2% confidence interval: –1.3% to +3.7%). Most suicides and disappearances (70%) were among customer service staff and, of 19 employed on large cruise ships, most (79%) were non-Europeans. Conclusions: The number of suicides and probable suicides is a cause for concern, especially among customer service staff on cruise ships. These findings indicate the need for interventions to reduce suicide risks. Further studies are needed to improve the targeting of interventions. These will need both to analyse the circumstances of individual deaths and derive suicide rates according to rank, department and nationality, based on reliable population denominators. (Int Marit Health 2020; 71, 1: 12–19) Key words: suicides, fatal accidents, cruise ships, passenger ferries, seafarers

INTRODUCTION The main aims of this study were firstly, to determine the In recent years, several studies have reported on mor- detailed causes and circumstances of fatalities from unnat- tality in passengers who have sailed in cruise ships and/or ural causes among crews employed in United Kingdom (UK) other types of passenger vessels [1, 2]. Many other stud- and Bermuda registered passenger ships from 1976 to 2018, ies have reported on morbidity in cruise ship passengers, and how they relate to factors including their rank on board including injuries [3–5], various communicable diseases and the type of passenger ship in which they were serving. including gastroenteritis and influenza [3, 6–10], and acute Secondly, to assess trends over time in mortality rates and cardiovascular diseases [11]. Little has been reported on to discuss preventative measures for reducing mortality. mortality and its causes among crew members who serve Over many decades, increased or high suicide rates have on board cruise or passenger ships. been reported quite consistently among seafarers employed in

* Dr. Tim Carter, Norwegian Centre for Maritime and Diving Medicine, Haukeland University Hospital, Norway, e-mail: [email protected]

12 www.intmarhealth.pl Tim Carter et al., Suicide, fatal injuries and drowning among the crews of UK and Bermuda registered cruise and passenger ships merchant shipping across Europe, when compared with gen- Deaths among non-crew members such as passengers and eral populations [12–17]. This has led to increasing concerns port workers were also excluded, as were deaths that occurred in recent years about suicide risks and suitable preventative when crews were signed off their ships. The study period was measures for seafarers. This study provides an opportunity to the 43 years from 1st January 1976 to 31st December 2018. look at the distribution of events by type of ship and the rank of the seafarers dying from this cause in passenger shipping. STUDY INFORMATION SOURCES Deaths at sea, including work-related deaths, in British MATERIALS AND METHODS shipping have not usually been registered with the local reg- INCLUSION CRITERIA istrars of deaths, nor included in central national mortality This study examined reported deaths from unnatural statistics or decennial census publications, but instead they causes among crew members who were “signed on” under have been registered separately at the Registry of Shipping articles of agreement (contracts) and working on board UK and Seamen. Deaths from accidents, injuries, drowning registered passenger ships of 100 gross registered tonnage and disappearances at sea are normally investigated by and over between 1976 and 2018. The study included only maritime authorities. In this study, details of deaths in UK those deaths that arose at work or within 30 days of any and Bermuda passenger shipping were identified mainly discharge ashore from work to hospital. This definition of from death inquiry files held by the UK’s principle maritime passenger shipping includes cruise ships, passenger carry- investigative authority, the Marine Accident Investigation ing ferries and a small number of other passenger vessels. Branch and from death inquiry files and death registers at As some of the major British cruise ships, such as the Queen the Registry of Shipping and Seamen. Other information Mary II, Queen Victoria, Arcadia and Caribbean Princess, sources used include Lloyd’s Register of Shipping casualty have been registered or re-registered with the Bermudan returns and data [19, 20], the British Newspaper Archive ship registry (a register in the Red Ensign group, based in [21], cruise shipping websites and other online searches. a UK Crown Dependency) the study additionally and similarly included all crew deaths in Bermudan registered passenger POPULATIONS AT RISK vessels during the same study period. In 2010, UK and The numbers of crew employed in UK and Bermudan Bermuda accounted for 6.7% of the world’s 524 cruise passenger ships is not available from any information ships and 2.8% of the world’s 6810 passenger ships [18]. source. However, the numbers of passenger ships regis- The study excluded deaths among crews who were employed tered annually with the UK and Bermudan ship registries in merchant vessels other than passenger ships, such as cargo were obtained from Lloyd’s Register of Shipping publications and offshore supply ships, and in all other forms of water-craft. [18]. These show (Fig. 1) a very moderate reduction in the

200 UK Bermuda

150

100 umber of passenger ships N 50

0 1976 1980 1984 1988 1992 1996 2000 2004 2008 2012 2016 Year

Figure 1. Numbers of United Kingdom (UK) and Bermuda registered passenger ships over time

www.intmarhealth.pl 13 Int Marit Health 2020; 71, 1: 12–19 numbers of passenger ships under the two flags combined, RESULTS particularly in the most recent years and with a modest Overall, there were 140 crew deaths identified, 127 in interim peak in the years around 2005. However, both UK and 13 in Bermuda registered passenger ships. Apart cruise ships and passenger ferries have increased in size from the Herald of Free Enterprise disaster in 1987, the over time, especially in the smaller Bermudan fleet through passenger ships from which most crew fatalities occurred the registration of several very large cruise ships in the last were the Queen Elizabeth II (11 deaths from 1978 to 2004), 15 years, including the Queen Mary II and the Queen Victo- and the Canberra (7 deaths from 1976 to 1993). ria. Although crewing levels as well as the numbers of ships One hundred and thirty-five of the 140 (96%) were men, have fallen over time, increases in the sizes of the ships the mean age was 37.2 years (standard deviation [SD]: 11.9; means that the total crew employed in UK and Bermudan range: 17–63 years). 90 (64%) of the 140 deceased were passenger shipping is likely to have remained quite stable British. The remainder were other European (16), Asian or increased slightly over the 43-year study period [18]. (22), other nationalities (7) or unspecified nationality (5). The deceased were employed in the deck (39), engine (25) METHODS OF ANALYSIS and customer service (86) departments. The main study factors assessed were, firstly, the rank The 140 crew fatalities were from accidents and drown- of the deceased at the time of death, which was categorised ing (91), suicides and disappearances at sea (38), homicide, as ship captains; deck officers; engineers; deck ratings; other and unexplained causes (11; Tables 1 and 2). engine room ratings; and customer service staff. Two fatalities among radio officers were included with deck officers SUICIDES AND DISAPPEARANCES AT SEA and two deaths among “other” staff were included with Of 13 recorded as suicides, 6 jumped overboard, customer service staff, there were no deaths among cadets. 6 were found hanged and 1 died through other means. The type of ship was classified into three categories; large 25 further crew who disappeared at sea also most likely cruise ships (≥ 40,000 gross tonnage), small or medium size jumped overboard, based on examination of death inquiry files, passenger ships (< 40,000 gross tonnage) and passenger crew statements and marine accident investigation reports. ferries (that mostly ranged 3,000–15,000 gross tonnage). The mean age at death at the time of suicide or disap- The main outcome measure was mortality by cause of pearance was 36.3 years (SD: 12.4; range: 18–61 years), death. Cause of death was grouped into accidents, suicides, 95% male. All but 5 of the 38 deaths arose at sea; from homicides and other or unexplained causes. Historically, cruise or passenger ships in the North Atlantic and Carib- many crew have disappeared at sea, and these deaths have bean Sea (7), North Pacific and South Pacific (8) and other usually been categorised with suicides, while others that seas (9) and from ferries around the UK (9). have been found drowned, often in docks and rivers when Most of the 38 deceased (27; 71%) were employed as off-duty, have conventionally been included with accidents. customer service staff and most of these (19; 70%) were A previous study of UK shipping found through examination employed on large cruise ships, the others were on ferries of death inquiry files and crew statements that more than or small/medium size passenger ships. Of the 19 who 80% of disappearances at sea were most likely suicides and were employed as customer service staff in large cruise that more than 80% of ‘found drowned’ cases were most ships, most (63%) were Asian and three others were also likely accidents [22]. non-European. In the most recent years, suicides and dis- Accidents were grouped into three categories; ship appearances at sea largely involved customer service staff accidents, involving an accident or incident to the pas- who were employed on board large cruise ships (Fig. 2). As senger ship, such as capsize, foundering or fire; (on-du- reliable data on the crewing pattern on these vessels are ty) occupational accidents, affecting crews individually not publically available it is not possible to compare rates during work duties; and off-duty accidents which occur of suicide, but only to point to the numbers of deaths. during leisure time. Mortality rates were expressed per There has been no significant reduction in mortality 100 (passenger) ship-years. Logistic regression modelling from suicides and disappearances over the 43-year study was used to assess mean annual changes in mortality period (mean annual reduction: 1.2%; 95% CI: –1.3% to rates and their significance through 95% confidence in- +3.7%; Fig. 3). tervals (CI). Fisher’s exact test was used to compare crew nationality groupings (British; other European; Asian; other MORTALITY FROM ACCIDENTS AND DROWNING nationalities; unspecified nationality) for seafarers who died The 91 fatal accidents and drowning include 46 from through accidents and drowning, compared with suicides ship accidents, largely through the Herald of Free Enter- and disappearances at sea. Significance was based on the prise disaster off Zeebrugge in 1987 (38 crew lost along conventional 5% level. with 155 passengers) and a collision between two passen-

14 www.intmarhealth.pl Tim Carter et al., Suicide, fatal injuries and drowning among the crews of UK and Bermuda registered cruise and passenger ships

Table 1. Causes of all crew fatalities from unnatural causes in United Kingdom and Bermuda registered passenger ships, 1976–2018

Rank of the deceased Captains Deck Engineers Deck Engine Customer (Total) officers ratings room service Cause of death ratings staff Accidents and drowning Ship accidents:* Foundered or capsized 1 2 3 4 29 (39) Collisions 1 2 1 (4) Fires or explosions 2 1 (3) Occupational accidents: Lifeboat testing drills 3 (3) Falls on board 1 2 1 (4) Struck by mooring ropes 2 1 (3) Struck by motor vehicles on decks 1 1 (2) Struck/crushed by watertight doors 3 2 (5) Struck by other moving objects 2 1 (3) Scalded in engine rooms 2 (2) Other occupational accidents 2 1 (3) Off-duty accidents and drowning: Swimming or bathing accidents 1 5 (6) Traffic-related accidents ashore 1 1 1 2 (5) Falls on board 1 1 (2) Falls in docks, returning to ship 2 1 (3) Other drowning 1 3 (4) All other deaths from unnatural causes 1 1 14 1 32 (49) Total 1 5 10 33 15 76 (140) *Includes 38 crew fatalities through the capsize of the Herald of Free Enterprise passenger ferry

Table 2. Causes of all crew fatalities from unnatural causes according to the type of ship in United Kingdom and Bermuda registered passenger ships, 1976–2018

Type of passenger ship Large cruise Small/medium Passenger (Total) Cause of death ships passenger ships ferries Accidents and drowning: 13 (25%) 10 (19%) 30 (55%) (53, 100%) Ship accidents* 1 1 6 (8) Occupational accidents 6 4 15 (25) Off-duty accidents and drowning 6 5 9 (20) Suicides and disappearances at sea 23 (61%) 3 (8%) 12 (32%) (38, 100%) Homicide, other and unexplained causes 7 1 3 (11) Total 43 14 45 (102) *Excludes the 38 crew fatalities through the capsize of the Herald of Free Enterprise passenger ferry

www.intmarhealth.pl 15 Int Marit Health 2020; 71, 1: 12–19

A 4 Captains, deck officers and engineers Deck and engine room ratings Customer service staff

2 umber of suicides N

0 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year

B 4 Passenger ferries Small/medium passenger ships Large cruise ships

2 umber of suicides N

0 1975 1980 1985 1990 1995 2000 2005 2010 2015 Year

Figure 2. Trends in suicides and disappearances at sea among crew in United Kingdom and Bermuda registered passenger ships, 1976–2018, according to: rank of the deceased (A), and type of passenger ship (B)

ger ferries in the North Sea off Harwich in 1982 (4 fatali- different nationality profile to those who died through suicide ties). 25 fatal occupational (personal, on-duty) accidents or disappearance at sea (p = 0.002). Most fatal occupational or drowning refer largely to seafarers who were crushed accidents affected deck or engine room ratings (15; 60%), in watertight doors, falls on board, vehicle injuries on fer- whereas most off-duty accidents occurred among customer ries, struck by mooring ropes and davits breaking during service staff (12; 60%; Table 1). lifeboat testing drills. 20 off-duty accidents and drownings There has been a significant reduction over time in mor- were largely from swimming and bathing accidents from tality from accidents and drowning (mean annual reduction: beaches, traffic accidents ashore and falls into or drowning 4.3% per annum; 95% CI: 2.1–6.5%; Fig. 3). in docks (Table 1). The mean age at the time of accident or drowning was HOMICIDES AND OTHER DEATHS FROM 37.0 years (SD: 12.1; range: 17–63). Three of the 91 (3%) UNNATURAL CAUSES crew who died from accidents and drowning were female. 73 Three homicides were due to injuries involving non-UK were British and 10 were other European, and 8 were Asian crew members of 2 large cruise ships and a UK crew mem- or of other or unspecified nationality, with a significantly ber of an Irish Sea passenger ferry. Eight other deaths from

16 www.intmarhealth.pl Tim Carter et al., Suicide, fatal injuries and drowning among the crews of UK and Bermuda registered cruise and passenger ships

coastal-trading cargo ships [14, 22]. The reduction since A Fatal accidents and drowning the 1970s in mortality from accidents and drowning in 3 Suicides and disappearances at sea passenger shipping is comparable with similar reductions

ears) over time in merchant shipping more generally [22]. It could be expected that ferries with their usually short

00 ship-y 2 and regular passages would have relatively lower case fatality than other forms of shipping, given speedy access e (per 1 to shore based services, while cruise liners, with their well 1

tality rat equipped and staffed medical centres would also be ex-

Mor pected to have better outcomes and hence lower mortality arising from injury events. 0 1975 1980 1985 1990 1995 2000 2005 2010 2015 The outstanding feature of the study is the predomi- Year nance of suicides and disappearances at sea in the cruise sector, with a stable level during the study period against B Ship accidents a background of falling numbers of deaths from accidents 3 Occupational accidents

ears) Off duty accidents and drowning and injury. The observation that a high proportion of sui- Suicides and disappearances at sea cides on large cruise ships occurred among, mainly Asian,

00 ship-y 2 male customer service crew, although the numbers were small, may reflect the high proportion of crewmembers

e (per 1 from Asia who are performing these duties. It does how- 1 ever indicate the importance of targeting interventions to

tality rat reduce suicide risk at this group if the overall numbers of Mor suicides are to be reduced. Because of the limitations of 0 the available data it is not possible to calculate mortality 1975 1980 1985 1990 1995 2000 2005 2010 2015 rates using the at-risk populations employed and so the Year number of ships registered has been used as a less than ideal surrogate for this. As in other studies [23], some Figure 3. Trends in mortality from accidents and drowning, suicide and disappearances at among crew in United Kingdom deaths from other unnatural and unexplained causes may (UK) and Bermuda registered passenger ships, 1976–2018; also have been due to suicide. A. With types of accidents and drowning combined; B. With types Recent reviews and reports have identified a number of accidents and drowning disaggregated by type. Notes: Mortality of uncertainties and controversies about the importance of rates are smoothed using 5 year moving averages. Excludes the suicide as a cause of death in seafarers and the contributory 38 fatalities through the capsize of the Herald of Free Enterprise passenger ferry in 1987 causes for this, notably the experience of social isolation among seafarers [24, 25]. Customer service staff, who are mainly recruited from Asian countries, tend to have longer unnatural or inconclusive cases were due to alcohol and periods away from their home and at sea, often of the order drug intoxication (2), unexplained injuries (2), asphyxiation of 9 months, than other groups of crew. They may not define through an acute schizophrenia episode and on vomit (one themselves as career seafarers and thus be accepting of each) and unspecified causes (2). the way of life on board, also they are working in an environment that is managed by crew with ethnic backgrounds DISCUSSION and expectations that differ from their own. All of these The study includes two related national ship registers aspects may exacerbate social isolation with its attendant and is limited to passenger vessels, a sector now dominated risks. Findings from other sectors of employment indicate by cruise ships and passenger/vehicle ferries. Mortality from that low skilled trades, caring, leisure and other service accidents is typically lower in passenger shipping than in occupations have high suicide rates relative to the general cargo-carrying shipping sectors, where a high proportion of population [26, 27]. Other contributory factors in these accidents are linked to cargo-related operations, such as sectors, which may be in common with on board customer asphyxiation or falls in cargo holds, cargo-related crush- service crew, are socio-economic, including low pay, low job ing injuries or falls overboard (which are largely absent in security and low socio-economic status [28]. The number passenger shipping), as well as falls in docks when return- of female suicide cases is low, especially in relation to the ing to ships from ashore and casualties involving small proportion of female customer service crew. This may reflect

www.intmarhealth.pl 17 Int Marit Health 2020; 71, 1: 12–19 the lower incidence of suicide in females found in studies 2. Oldenburg M, Herzog J, Püschel K, et al. Mortality of German travel- in other settings. lers on passenger vessels. J Travel Med. 2016; 23(1), doi: 10.1093/ jtm/tav003, indexed in Pubmed: 26782123. Strengths of this investigation are that it is the first 3. Bansal V, Fortlage D, Lee JG, et al. Significant injury in cruise study that has focussed specifically on the mortality of ship passengers a case series. Am J Prev Med. 2007; 33(3): crews who are employed on board cruise and passenger 219–221, doi: 10.1016/j.amepre.2007.05.004, indexed in Pub- ships. It is based on two large defined populations serving med: 17826583. UK and Bermuda registered passenger ships and covers 4. Bekic M, Mikolaucic M, Golubovic M, et al. A three-year follow-up a long 43-year study period to assess trends in mortality. It on injuries sustained by cruise ship passengers and crew treated at the Orthopaedic and Traumatology Department at Dubrovnik is also based on reliable information sources that have been County Hospital. Injury. 2015; 46 Suppl 6: S73–S77, doi: 10.1016/j. used in previous investigations of mortality in the maritime injury.2015.10.039, indexed in Pubmed: 26612476. industries [16, 22, 23]. The major study limitation is that the 5. Isom WJ, Accilien YD, Chery SB, et al. Patterns of injury amongst numbers of crew employed in UK, Bermuda and almost all cruise ship passengers requiring hospitalisation. Int Marit Health. other passenger fleets world-wide are not known. Mortality 2018; 69(4): 243–247, doi: 10.5603/IMH.2018.0039, indexed in Pubmed: 30589063. rates have therefore been presented in terms of the much 6. Rooney RM, Cramer EH, Mantha S, et al. A review of outbreaks inferior numbers of passenger ship-years, rather than ac- of foodborne disease associated with passenger ships: evi- cording to the person-years employed, so that the findings dence for risk management. Public Health Rep. 2004; 119(4): on trends in mortality should be considered as indicative. 427–434, doi: 10.1016/j.phr.2004.05.007, indexed in Pubmed: It is also likely that the notification, documentation and 15219800. therefore study ascertainment of fatal accidents, through 7. Cramer EH, Blanton CJ, Blanton LH, et al. Vessel Sanitation Pro- gram Environmental Health Inspection Team. Epidemiology of the maritime authorities, would have been more complete gastroenteritis on cruise ships, 2001-2004. Am J Prev Med. 2006; than for suicides and homicides. 30(3): 252–257, doi: 10.1016/j.amepre.2005.10.027, indexed in Pubmed: 16476642. CONCLUSIONS 8. Schlaich CC, Oldenburg M, Lamshöft MM. Estimating the risk of These results do not immediately point to specific re- communicable diseases aboard cargo ships. J Travel Med. 2009; 16(6): 402–406, doi: 10.1111/j.1708-8305.2009.00343.x, in- medial actions, although recent reports do make a series dexed in Pubmed: 19930380. of potential proposals, such as reducing stigma around 9. Payne M, Skowronski D, Sabaiduc S, et al. Increase in Hospi- mental health issues and social isolation, promoting positive tal Admissions for Severe Influenza A/B among Travelers on social environments for staff on-board seafarer communities Cruise Ships to Alaska, 2015. Emerg Infect Dis. 2018; 24(3): and peer support programmes [29]. Our findings would 566–568, doi: 10.3201/eid2403.171378, indexed in Pubmed: be enhanced by improvements in the documentation of 29460744. 10. Pavli A, Maltezou HC, Papadakis A, et al. Respiratory infections and non-accidental deaths in passenger shipping and in the gastrointestinal illness on a cruise ship: a three-year prospective maritime industries more generally, compared with that for study. Travel Med Infect Dis. 2016; 14(4): 389–397, doi: 10.1016/j. fatal accidents. Also by further studies in the cruise sector tmaid.2016.05.019, indexed in Pubmed: 27320130. that would be able to assess the detailed circumstances 11. Novaro GM, Bush HS, Fromkin KR, et al. Cardiovascular emer- surrounding incidents of suicide and disappearance at sea gencies in cruise ship passengers. Am J Cardiol. 2010; 105(2): 153–157, doi: 10.1016/j.amjcard.2009.09.004, indexed in using psychological autopsy methodologies as well as using Pubmed: 20102910. baseline population information on gender, age, ethnicity, 12. Otterland AA. sociomedical study of the mortality in merchant seafa- rank and ship department in the populations at risk. rers. Gotebörg: Scandinavian University Books. 1960. 13. Wickström G, Leivonniemi A. Suicides among male Finnish seafarers. ACKNOWLEDGEMENTS Acta Psychiatr Scand. 1985; 71(6): 575–580, doi: 10.1111/j.1600- The authors thank Cathy Pennock, Audrey Hodges 0447.1985.tb02551.x, indexed in Pubmed: 4024973. 14. Hansen HL. Surveillance of deaths on board Danish merchant and the Marine Accident Investigation Branch for helpful ships, 1986-93: implications for prevention. Occup Environ Med. advice and provision of marine accident investigation 1996; 53(4): 269–275, doi: 10.1136/oem.53.4.269, indexed in files; John Crilley and Vaughan Pomeroy for help and Pubmed: 8664966. advice with Lloyd’s Register of Shipping casualty returns 15. Szymańska K, Jaremin B, Rosik E. Suicides among Polish seamen and data; and librarians at the Registry of Shipping and and fishermen during work at sea. Int Marit Health. 2006; 57(1-4): 36–45, indexed in Pubmed: 17312692. Seamen for providing access to death inquiry files and 16. Roberts SE, Jaremin B, Chalasani P, et al. Suicides among seafa- death registers. rers in UK merchant shipping, 1919-2005. Occup Med (Lond). 2010; 60(1): 54–61, doi: 10.1093/occmed/kqp133, indexed in REFERENCES Pubmed: 19805397. 1. Dahl E. Passenger mortalities aboard cruise ships. Int Marit Health. 17. Iversen RTB. The mental health of seafarers. Int Marit Health. 2012; 2001; 52(1-4): 19–23, indexed in Pubmed: 11817837. 63(2): 78–89, indexed in Pubmed: 22972547.

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18. Lloyd’s Register of Shipping. World fleet statistics [annual returns, 25. Mellbye A, Carter T. Seafarers’ depression and suicide. Int Marit 1976-2018]. London: Lloyd’s Register of Shipping: 1977-2019. Health. 2017; 68(2): 108–114, doi: 10.5603/IMH.2017.0020, 19. Lloyd’s Register of Shipping. Casualty data (casualty data from indexed in Pubmed: 28660614. Lloyd’s Register. 26. Windsor-Shellard B, Gunnell D. Occupation-specific suicide 20. Lloyd’s Register of Shipping. Casualty returns, 1976-2010. London: risk in England: 2011–2015. Br J Psychiatry. 2019 [Epub Lloyd’s Register of Shipping: 1977-2011. ahead of print]: 1–6, doi: 10.1192/bjp.2019.69, indexed in 21. British Newspaper Archive (www.britishnewspaperarchive.co.uk; Pubmed: 30929655. last accessed September 18th. 2019. 27. Office for National Statistics. Suicide by occupation, England: 2011 22. Roberts SE, Marlow PB. Traumatic work related mortality among to 2015 . http://www.ons.gov.uk/peoplepopulationandcommunity/ seafarers employed in British merchant shipping, 1976-2002. birthsdeathsandmarriages/deaths/articles/suicidebyoccupation/ Occup Environ Med. 2005; 62(3): 172–180, doi: 10.1136/ england2011to2015 (last accessed September 18th 2019). oem.2003.012377, indexed in Pubmed: 15723882. 28. Agerbo E, Gunnell D, Bonde JP, et al. Suicide and occupation: 23. John A, McGregor J, Jones I, et al. Premature mortality among pe- the impact of socio-economic, demographic and psychiatric diffe- ople with severe mental illness - New evidence from linked primary rences. Psychol Med. 2007; 37(8): 1131–1140, doi: 10.1017/ care data. Schizophr Res. 2018; 199: 154–162, doi: 10.1016/j. S0033291707000487, indexed in Pubmed: 17445281. schres.2018.04.009, indexed in Pubmed: 29728293. 29. Summary report from the ITF Seafarers’ Trust Autumn 2016 24. Carter T, Williams JG, Roberts SE. Crew and passenger deaths from workshop on social isolation, depression and suicide (SIDS). www. vessel accidents in United Kingdom passenger ships since 1900. Int seafarerstrust.org/wp-content/uploads/2018/07/Seafarers-Social- Marit Health. 2019; 70(1): 1–10, doi: 10.5603/IMH.2019.0001, -Isolation-Depression-and-Suicide-Workshop-Write-Up-August2016. indexed in Pubmed: 30931511. pdf (last accessed September 18th 2019).

www.intmarhealth.pl 19 Int Marit Health 2020; 71, 1: 20–27 10.5603/IMH.2020.0007 www.intmarhealth.pl ORIGINAL ARTICLE Copyright © 2020 PSMTTM ISSN 1641–9251 Field study of anthropomorphic and muscle performance changes among elite skippers following a transoceanic race

Pierre Lafère1, 2, 3 , Yann Gatzoff4, François Guerrero2 , Steven Provyn3, 5, 6 , Costantino Balestra3, 5, 6, 7

1Department of Anaesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium 2ORPHY Laboratory EA4324, Université de Bretagne Occidentale, Brest, France 3Environmental, Occupational, Ageing (Integrative) Physiology Laboratory, Haute Ecole Bruxelles-Brabant (HE2B), Brussels, Belgium 4Geneva University Hospitals, Geneva, Switzerland 5Anatomical Research Training and Education (ARTE), Vrije Universiteit Brussel (V.U.B.), Brussels, Belgium 6Anatomical Research and Clinical Studies (ARCS), Vrije Universiteit Brussel (V.U.B.), Brussels, Belgium 7Motor Sciences, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium

Abstract Background: Ocean racing has become increasingly demanding, both physically and psychologically. The aim of the study was to assess global changes after a transoceanic race. Materials and methods: Eight male sailors were evaluated pre- and post-race through anthropometric measurements (weight, skinfold, girth at different level and estimated body fat percentage), multifrequency tetrapolar bioelectrical impedance, muscular performance, visual analogic scale for perceived fatigue and Critical Flicker Fusion Frequencies for cerebral arousal. Results: Compared to pre-race values, a significant decrease in body weight (–3.6 ± 1.4%, p = 0.0002) and body composition with reduction of body fat percentage (–15.1 ± 3.5%, p < 0.0001) and fat mass (–36.4 ± 31.4%, p = 0.022) was observed. Muscle performance of the upper limb was preserved. In the lower limb, monohulls skippers showed a significant reduction of jump height (–6.6 ± 4.8%, p = 0.022), power (–11.7 ± 7.3%, p = 0.011) and speed (–14.6 ± 7.4%, p = 0.0006) while a multihulls skipper showed a gain in speed (+0.87%), power (+8.52%), force (+11%) resulting in a higher jump height (+1.12%). These changes were inversely correlated with sea days (Pearson r of –0.81, –0.96 and –0.90, respectively, p < 0.01). Conclusions: Changes in body weight and composition are consistent with previous data indicating a probable negative energy balance. The main finding demonstrates a difference in muscular conditioning between upper and lower limbs that might be explained by differential workload related to boat architecture (trampolines) or handling. (Int Marit Health 2020; 71, 1: 20–27) Key words: anthropometry, skinfold thickness, impedance, bioelectrical, weight loss, flicker fusion, muscle strength

INTRODUCTION tend to go faster. For instance, 60-feet monohulls boat Ocean racing has changed a lot in the last 30 years. Boat from the International Monohulls Open Class Association designers have tried to find ways to increase power, while (IMOCA), completing the round-the-world solo race (“Vendee reducing weight, however with few concessions to sailor’s Globe”: 21,638 nautical miles), decreased the time needed comfort. Therefore, these high-performance racing boats from under 100 days in 2001, down to 90 days in 2005,

Pierre Lafère, PhD, Department of Anaesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium, * e-mail: [email protected]

20 www.intmarhealth.pl Pierre Lafère et al., Differential effect of offshore race on limbs below 85 days in 2009, 78 days in 2013 and to finally reach an IMOCA and 1 sailing a Multi 50) volunteered to partic- 74 days in 2017. ipate and signed a written informed consent. The study Consequently, boats handling has become increasingly was approved by the local Academic Bio-Ethical Committee demanding, both physically and psychologically. Indeed, of Brussels (CE2008/66) and was conducted in accordance offshore racing is an arduous activity involving hard mental with the Declaration of Helsinki [19]. All participants were and physical work carried out in strenuous environmental subjected to the same data collection procedure, which was conditions. The watch system makes it impossible to get applied before the race and within 6 hours after arrival in a full night sleep deterring physical and mental performance Puerto Limón. Therefore, each skipper is his own control. as well as meal frequency [1]. Also, according to the nature Anthropometric measurements performed by the same of their sport, sailors involved in offshore racing can be qualified investigator with 5 years of experience followed the exposed to injuries and other health problems that can protocol of the International Society for the Advancement endanger their lives [2]. Unfortunately, the distance from of Kinanthropometry (ISAK) [20] and include body mass onshore health facilities and lack of professional presence measured to the nearest 0.05 kg with a digital scale (SECA on board might explain why only scarce scientific data are 220, Seca gmbh & Co., Hamburg, Germany), skinfolds at six available. A review based on a systematic search of medical different sites (triceps, subscapular, supra-spinal, abdominal databases employing predefined criteria, using the terms [umbilical], anterior tight, medium calf) using a Harpenden offshore racing/sailing, solo sailing or open sea racing could calliper (Harpenden skinfold calliper, Bay international, West only identified less than 20 publications on the subject over Sussex, England), and girths at six different sites (arm girth the last 40 years [2–15]. All those studies only included relaxed, forearm, supra-patellar, thigh, mid-thigh, medial calf) a very limited number of subjects (case report to a dozen with a flexible anthropometric steel tape (Lufkin W606PM, individuals), albeit a very specific population (Caucasian cooper industries, Ohio, United States) to the nearest 0.1 cm. males in their mid-thirties) and were mostly focused on By convention, all anthropometrical measurements were taken energy expenditure/intake and sleep deprivation. on the right side of the body (all skippers were right-handed). More data are available about the physiological chal- Each measurement was taken twice. If the difference be- lenges of competitive sailing, for instance related to the tween the first and the second reading was > 5% for skinfolds America’s Cup [16, 17], albeit this is not the exact same and > 1% for girths, a third measurement was taken and the sailing discipline as the later ignores the continuous de- mean of the two nearest measurements was calculated as manding efforts of long-haul sailing. According to a recent the final value. Percentage body fat (%BF) was calculated review [18], the most influential factors in determining using the Yuhasz formula (%BF = 0.1051 × (∑6 skinfolds) sailing performance, including dinghy sailing with smaller + 2.585) [21], because it was designed for athletes and fit boats like Laser or the “America’s Cup” with large boats, individuals, which is the case of our population [22]. are related to the sailor’s physical characteristics, sailing Since biometrical multifrequency impedance analysis techniques, decision-making abilities, tactical skills or psy- (BIA) is a widely accepted method for the determination of chological characteristics. body composition (total body water [TBW], extracellular fluid In competitive sailing, there are different types of boats [ECF] and intracellular fluid [ICF]) due to its simplicity, speed that demand various types of effort by the sailor, which is and non-invasive nature [23], we used a single channel, why knowledge of their specific physical and physiological tetra polar bioimpedance spectroscopy device that scans features for each type of vessel is necessary. Unfortunately, 256 frequencies between 4 kHz and 1000 kHz for the es- the field of ocean racing remains mostly unexplored. To find timation of body composition in healthy individuals (SFB7, out more about this issue, the Pen Duick company (Paris, Impedimed Inc., Carlsbad, USA). Fat-free mass (FFM) and France) gave us the opportunity to carry out measurements fat mass (FM) are then calculated on the device. on skippers participating in the two-handed 2009 “Tran- Strength assessment included measurement of the sat Jacques Vabre” between Le Havre, France and Puerto maximal voluntary handgrip strength (HGS) and the vertical Limón, Costa Rica (4335 nautical miles). jump performance [24]. To avoid injury, a standard warm-up Therefore, the aim of the study was to assess global routine, consisting of jumping, stretching and gripping at physical changes among offshore skippers with a specific submaximal intensity preceded the actual tests. HGS was focus on muscular strength after a transoceanic race. measured three times with an electronic hand dynamometer (Newgen medical EH101, Pearl, Buggingen, Germany) [25] MATERIALS AND METHODS and the mean value was used for analysis and compari- After being informed of the purpose and experimen- son. Vertical counter movement jump performance was tal procedures of the study, 8 Caucasian male skippers assessed using an accelerometer (Myotest, Myotest Inc., without any of them paired on the same boat (7 sailing Sion, Switzerland) [26]. A total of 5 maximal vertical jumps

www.intmarhealth.pl 21 Int Marit Health 2020; 71, 1: 20–27

Table 1. Pre- and post-transoceanic race anthropometric data of offshore sailors (n = 8)

Pre-race Post-race P (Paired t test) Weight [kg] 81.8 ± 10.1 78.9 ± 10.1 0.0002** Body mass index [kg/m2] 25.4 ± 1.1 24.5 ± 1.3 0.0001** Percentage of body fat [%BF]# 12.2 ± 2.4 10.4 ± 2.3 < 0.0001** Skinfold [mm]: Triceps 13.9 ± 5.2 10.6 ± 3.7 0.0019* Subscapular 18.5 ± 5.2 15.0 ± 4.5 0.0011* Supra-spinal 17.6 ± 6.2 14.9 ± 5.9 < 0.0001** Umbilical 25.6 ± 6.7 18.7 ± 7.9 0.0002** Front tight 9.7 ± 2.8 9.5 ± 2.5 0.516 Medium calf 6.4 ± 2.6 5.9 ± 2.6 0.227 Girth [cm]: Forearm 29.7 ± 1.7 29.8 ± 1.4 0.557 Arm 29.9 ± 1.9 30.3 ± 1.5 0.161 Thigh 53.2 ± 2.7 51.7 ± 3.0 0.0025* Mid-thigh 45.6 ± 3.5 44.2 ± 3.7 0.0095* Supra-patellar 39.4 ± 3.2 39.1 ± 3.2 0.139 Medium calf 38.0 ± 1.3 37.6 ± 1.1 0.111 *p < 0.01; **p < 0.001; #Calculated according the Yuhasz formula (%BF = 0.1051 × (∑6 skinfolds) + 2.585)

were evaluated and accelerometric data were stored during Since all data passed the Kolmogorov-Smirnov test, the assessments and subsequently downloaded for jump allowing us to assume a Gaussian distribution, they were height (cm), power (w/kg), force (N/kg), and speed (cm/s) analysed with a Student’s paired t-test or a one-way ANOVA calculations. The mean for each value, calculated on the with Bonferroni post-hoc test. three highest jumps, was used for analysis and comparison. Since each skipper is his own control, taking the pre-race In the present study, non-muscular fatigue (central) values as 100%, percentage changes were calculated for was assessed by means of Critical Flicker Fusion Frequen- each parameter, allowing an appreciation of the magnitude cy (CFFF) and by a 100-mm visual analogue scale (VAS). of change between each measurement rather than the CFFF was assessed with a specific watertight device (Hu- absolute values. man Breathing Technology, Trieste, Italy) previously fully Existing correlation between significant statistical re- described by Balestra et al. [27]. Thanks to the design of the sults and age, initial weight or days at sea was assessed device, it is impossible for the subjects to be aware of the through a Pearson correlation coefficient test and linear actual flicker frequency through the whole test. When there regression when possible. is a change in LED light from fusion to flicker (or flicker to All tests were performed using a standard computer sta- fusion), the subject acknowledges it to the investigator and tistical package, GraphPad Prism version 5.00 for Windows the reached frequency is recorded. For each sample, the (GraphPad Software, San Diego California USA). A threshold mean of three consecutive tests was calculated and used for of p < 0.05 was considered statistically significant. All data analysis. For VAS testing, we used the same methodology as are presented as mean ± standard deviation (SD). in Lafère et al. [28] where the same VAS scale is presented twice but in opposite directions: one asked to evaluate the RESULTS ‘energy level’ (from sleepy/0 to energetic/10), the second The mean age of the 8 subjects was 39.7 ± 5.3 years asked to evaluate the “tiredness level” (from energetic/0 to and height 1.79 ± 0.97 m. All other anthropometric char- sleepy/10). Should the difference between the first and the acteristics pre- and post-race are summarised in Table 1. second reading be > 10%, a third measurement (“tiredness We observed a significant decrease in body weight (–3.6 ± level”) was taken and the mean of the two nearest mea- ± 1.4%) from 81.8 ± 10.1 to 78.9 ± 10.1 kg (p = 0.0002, surements was calculated as the final value. paired t-test, df = 7) and a similar significant reduction of

22 www.intmarhealth.pl Pierre Lafère et al., Differential effect of offshore race on limbs

A 120 B 100

*** *** *** 100 80 *** alues alues ol v ol v

** 80 60

% of contr * % of contr

60 40 TBW ECF ICF FFM FM Right Left Right Left Trunk leg leg arm arm

Figure 1. Percentage variation of global impedancemetry (A) and segmental fat mass (B) after a transoceanic race (n = 8). Pre -race value is taken as 100%. Each subject is compared to his own pre-race value. Means and standard deviations are shown in graph; ***p < 0.001; **p < 0.01; *p < 0.05; TBW — total body water; ECF — extracellular fluid; ICF — intracellular fluid; FFM — free fat mass; FM — fat mass

110 150 **

100 alues alues ol v ol v * 100 *

* 90

** % of contr % of contr *

80 50 Jump height Speed Power Force CFFF VAS

Figure 2. Percentage variation of lower limb muscle performan- Figure 3. Percentage variation of perceived fatigue after ce after a trans-oceanic race (n = 8). Pre-race value is taken a trans-oceanic race (n = 8). Pre-race value is taken as 100%. as 100%. Each subject is compared to his own pre-race Each subject is compared to his own pre-race value. Means and value. Means and standard deviations are shown in graph; standard deviations are shown in graph; **p < 0.001; *p < 0.05; **p < 0.001; *p < 0.05 CFFF — Critical Flicker Fusion Frequency; VAS — Visual Analog Scale the body mass index (BMI: –3.2 ± 1.7%) from 25.4 ± 1.1 to Analysis of body composition by BIA (Fig. 1) showed no 24.5 ± 10.3 kg/m2 (p = 0.0001, paired t-test, df = 7). Based difference in hydration (TBW: from 55.4 ± 6.0 to 55.8 ± 5.3% on skinfold measurements and the Yuhasz formula, this of total weight, p = 0.571; ECF: from 22.7 ± 3.0 to 23.3 ± weight reduction seems to be associated with a modification ± 3.8% of total weight, p = 0.307; ICF: 32.7 ± 3.2 to 32.4 ± of body composition with a significant reduction of the %BF ± 1.6% of total weight, p = 0.878, paired t-test, df = 6) and (–15.1 ± 3.5%) from 12.2 ± 2.4 to 10.4 ± 2.3 % (p < 0.0001, FFM values (75.7 ± 8.2 to 75.7 ± 7.2 kg, p = 0.878 paired paired t-test, df = 7). However, this modification seems to t-test, df = 6). However, we observed a significant reduc- be at the expense of the upper body with some significant tion of FM (–36.4 ± 31.4%) from 6.6 ± 4.1 to 3.2 ± 0.9 kg decreased skinfolds at tricipital, subscapular, supra-spinal (p = 0.022 paired t-test, df = 6). Segmental impedance in- and umbilical level. No significant changes were identified dicated that this reduction in fat mass is evenly distributed on the lower limb. Unlike skinfold measurement, muscle between the different segments of the body. Although the circumference did not show significant change in the upper trunk presented the greater reduction of fat mass (–48.3 ± limb, while a significant decrease was noticed in the lower ± 28.1%), this result is not significant (p = 0.247, one-way limb at mid-tight and maximal thigh level. ANOVA, F (4, 30) = 1,433).

www.intmarhealth.pl 23 Int Marit Health 2020; 71, 1: 20–27

A 10 B 10 Days at sea 16 17 18 19 Days at sea 0 16 17 18 19 0 –10

–20 –10 –30 ariation [%] ariation [%] V V –40 –20 –50 Slope: –11.6 ± 2.57 Slope: –2.48 ± 0.74 R2: 0.77, P = 0.004 R2: 0.65, P = 0.015 –60 –30

C 10 D 10 Days at sea Days at sea 16 17 18 19 16 17 18 19 0 0

–10 –10 ariation [%] ariation [%] V V

–20 –20

Slope: –6.27 ± 0.7 Slope: –5.62 ± 2.01 R2: 0.93, P = 0.0001 R2: 0.82, P = 0.002 –30 –30

Figure 4. Correlation calculation and linear regression of the magnitude umbilical skinfold (A), body fat (%BF) (B), jump height (C) and speed (D) changes and days at sea (n = 8).

Muscle performance of the upper limb seemed to be after 15 days 15 hours, 31 minutes while the first IMOCA preserved as HGS values did not change significantly after crossed the line a few hours later after 15 days 19 hours and the race from 53.6 ± 8.3 to 51.8 ± 8.7 N (p = 0.228, paired 22 minutes and 4730 nautical miles of travelled distance. t-test, df = 7). On the contrary, results of the lower limb Our last volunteer crossed the finish line after 18 days showed significant impairment (Fig. 2). The speed (–6.6 ± 13 hours and 26 minutes. A Pearson correlation calculation ± 4.8%) and power (–11.7 ± 7.3%) developed by the exten- demonstrated that the magnitude of umbilical skinfold, %BF, sor muscles of the lower limbs during counter movement jump height and speed changes were inversely correlated jumps decreased from 237.8 ± 30.3 to 221.8 ± 28.0 cm/s with days at sea (Pearson r of –0.87, –0.81, –0.96 and (p = 0.022, paired t-test, df = 7) and from 44.8 ± 7.8 to –0.90, respectively; Fig. 4). Since all differences reached 39.7 ± 8.9 w/kg (p = 0.011, paired t-test, df = 5). Jump statistical significance (p < 0.01), we can reject the idea height was also significantly decreased (–15.5 ± 7.4%) that the correlation is due simply to random sampling. This from 29.3 ± 6.3 to 25.4 ± 6.1 cm (p = 0.0006, paired t-test, relation is further confirmed by linear regression. No other df = 7). However, the force (N/kg) developed by the same correlation could be found between statistically significant muscles, did not show any significant difference between results and age or initial weight. measurements made before and after the race (Force: 22.8 ± ± 3.1 vs. 22.4 ± 2.0 N/kg, p = 0.930, paired t-test, df = 7). DISCUSSION Perceived fatigue was significantly higher after the race Measuring physiological parameters during sailing rac- (Fig. 3). Subjective evaluation (VAS) showed an increase of es is technically and logistically difficult. Nonetheless, this 25.9 ± 19.3% in the level of tiredness at 126 ± 19.3% of study contributed valuable data on global physical changes pre-race value (p = 0.0067, paired t-test, df = 7), while ob- in the 2009 “Transat Jacques Vabre”, a two-handed offshore jective evaluation of cerebral arousal showed a consistent sailing race. decrease in CFFF by 5.6 ± 5.7% of CFFF at 94.4 ± 5.8% of Previous studies demonstrated that professional sail- pre-race value (p = 0.028, paired t-test, df = 7). ors incur severe sleep loss with marked performance im- To depict the magnitude of the race, the first multi pairment [8–11]. In case of prolonged sleep restriction, the 50 raced for 5050 nautical miles and crossed the line balance between sleep homeostasis and circadian rhythm

24 www.intmarhealth.pl Pierre Lafère et al., Differential effect of offshore race on limbs process is disturbed, which induces an adaptive response. cycling measured 10 days after completion of the race. Pressure for sleep during wakefulness increases and dis- A deeper look at skinfolds and muscle circumferences sipates exponentially during subsequent sleep, hence the could explain this difference. In the upper limb, we noticed efficacy of brief periods of sleep providing significant perfor- a significant reduction of skinfolds, confirming the loss of mance recuperation. However, sleep restriction practiced fat, while arm and forearm circumferences are not modi- on a chronic basis induces cumulative performance deficits fied suggesting a gain of muscle. On the opposite, in the [29]. Our results confirmed an increased perceived fatigue lower limbs, the skinfolds are not modified, while there is both on subjective (VAS) and objective assessment (CFFF). a significant reduction of the circumference of the thigh sug- Indeed, CFFF has been used with success in several models gesting a loss of muscle. Analysis of the different muscular of extreme exposure such as divers [28, 30], pilots [31] or activities when on board, could explain these results. Activity parabonauts [32] and has been seen as a global index of of the lower limbs is essentially static, often sub-maximal cerebral arousal, however with an easier set-up. Since, it whereas upper limbs activity, during race, is explosive and was demonstrated on short races that it was possible to often maximal (using grinders and winches to shape the minimise anxiety and perceived fatigue with adequate sleep sails in coordination with the trimmers boat) [36]. When to optimise performance and efficiency [8], it implies that outside, sailors usually stay in the cockpit located at the an improved arousal may be a surrogate of an improved helm, where the majority of ropes are positioned, allowing performance. We therefore advocate introducing CFFF mea- for sails adjustments. Except in the event of changing and surement into skipper’s individual assessment to better reefing sails, skippers avoid moving towards the bow. When identify the optimal moment or need for sleep. inside, the available room does not allow the skippers to As already demonstrated in several studies [4, 5, 7, 33], maintain an upright position, except for the smaller ones or we observed a significant reduction of bodyweight (–3.6 ± when the boat goes upwind. They remain seated in front of ± 1.4%) at the expense of FM (–36.4 ± 31.4%). According the chart table, in order to receive and study the weather to segmental BIA of FM, the reduction of fat mass was more forecasts, calculate the best route, or during bad weather pronounced in the abdomen (–48.3 ± 28.1%) than in the conditions. This can be clearly considered as a lower limb limbs (–25.1 ± 22.5%). Although not statistically significant, detraining [37]. Indeed, it is agreed that if activity is suffi- this trend makes sense as abdominal adipose tissue (both ciently reduced, muscle atrophy will ensue with associated visceral and subcutaneous) represents about 45% of the total loss of force and power [38, 39]. It is further interesting to adipose tissue volume among lean men between 39 and note that all of the participants within the study decreased 49 years [34]. Since it was not possible to assess the daily their performance (i.e. losing strength in the lower limb) nutritional intake, we can only assume a negative energy with one exception. Indeed, the only skipper of our sample balance. The hypothesis of negative energy balance makes engaged in multi 50 conserved his leg functionalities. He sense in regards of the significant reduction of waist circum- even ameliorated them with a gain in speed (+0.87%), power ference. Indeed, according to different studies the mean (+8.52%) and force (+11%) resulting in a higher jump height total daily energy expenditure during offshore race may vary (+1.12%). A shorter stay at sea compared to the other sailors between 14.5 [33] and 19.3 MJ/d [4], which is very high. might explain this. However, when compared to the fastest More, it was demonstrated on an offshore race of 500 nau- IMOCA participants, who arrived within hours of the multi tical miles long that the time spent performing sedentary 50 (difference of 3 h 50 min 20 s), the slope of the curve (< 1.5 METs, excluding sleeping) or light activity (between between pre- and postrace results are significantly different. 1.5 and 2.9 METs) predominates with an average of 92% of We can hypothesize that the presence of “trampolines” set the wake time [11]. This may be assimilated to an endurance between the portside/starboard hulls and the main hull exercise known to increase the maximum consumed oxygen, could be responsible for this. Indeed, continuously crossing improve the capability of skeletal muscles to produce energy of the trampolines to manoeuvre the boat requires greater via the aerobic system and to reduce weight [35]. range of motion in lower limbs, with increased torque and The main finding of our study reports a difference in bigger flexion allowing more intense muscular recruitment muscular conditioning between upper and lower limbs. in this type of activity [40] preserving leg physical capacity. Indeed, no loss of HGS was noticed while there is a clear Although both fatigue and loss of weight after an offshore and significant impairment of the leg physical capacity race were previously demonstrated, this provides some ex- with a reduction of jump height, speed and power. A recent ternal validity to our results. However, we were surprised case report has produced similar result after an oceanic by the extent of the reported changes and the difference race that lasted 64 days [1]. According to this report, this that a few days can make in weight, body composition and is explained by a leg disuse responsible for a decreased performance. Since we were limited by logistical constraint maximum oxygen uptake and maximum workload during and a very specific population, our sample was small. This

www.intmarhealth.pl 25 Int Marit Health 2020; 71, 1: 20–27 may have biased our results. However, using each skipper 6. Portier H, Chatard JC, Filaire E, et al. Effects of branched-chain amino as his own control mitigated any risks of underestimating acids supplementation on physiological and psychological performance during an offshore sailing race. Eur J Appl Physiol. 2008; or overestimating the magnitude of the changes. 104(5): 787–794, doi: 10.1007/s00421-008-0832-5, indexed in Pubmed: 18704484. CONCLUSIONS 7. Fearnley D, Sutton L, O’Hara J, et al. Case study of a female Even if our sample size was small, including only 20% ocean racer: prerace preparation and nutritional intake during the Ven- of skippers engaged in the race, we showed race-induced dée Globe 2008. Int J Sport Nutr Exerc Metab. 2012; 22(3): 212–219, impairment of fatigue, body weight, body composition, and doi: 10.1123/ijsnem.22.3.212, indexed in Pubmed: 22349112. 8. Hagin V, Gonzales BR, Candau RB, et al. 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www.intmarhealth.pl 27 Int Marit Health 2020; 71, 1: 28–33 10.5603/IMH.2020.0008 www.intmarhealth.pl REVIEW ARTICLE Copyright © 2020 PSMTTM ISSN 1641–9251 Lessons from a historic example of diving safety rules violation: the case of Greek sponge divers

Costas Tsiamis , Georgia Vrioni , Athanassios Tsakris

Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Greece

Abstract This study presents a historical example of systematic safety rules violations by professional sponge divers in Greece during the early 20th century. In light of absolute unaccountability in favour of economic competition and in the absence of state oversight, the profession of sponge diving had developed into a deadly undertaking. The study is based on a report compiled by Professor of Hygiene and Microbiology Konstantinos Savvas, which was addressed to the Ministry of Marine Affairs. Savvas’ report rested on data concerning hospitalised divers derived from the medical records of warship ‘Kriti’ (Crete), which escorted groups of Greek fishing vessels to four of their expedition in the Mediterranean over the period 1900–1903. Although the events explored herein took place at a time much different from the modern era with its numerous advancements in hyperbaric medicine, enhanced divers’ professionalism and the establishment of labour rights and strict safety regulations, we should not overlook the human factor of professional exploitation that leads to the violation of safety rules. On the other hand, supervisory authorities entrusted with the responsibility of overseeing professional activities ought to be vigilant on a constant basis, especially in times of economic crisis that may lead to lax state functioning. (Int Marit Health 2020; 71, 1: 28–33) Key words: decompression sickness, Greece, history, Konstantinos Savvas, sponge diving

INTRODUCTION ened employers to push towards increasing their profits in A professional diver has to perform a series of underwa- the name of competition. ter tasks using exclusively self-contained breathing appara- tuses. These tasks include underwater ship repairs, dock ARCHIVAL SOURCES construction, aquaculture, etc. Regardless of the needs or The study was based on two Greek archival sources: competition in market economies, however, divers’ compli- a) the report on decompression sickness (also known as the ance with safety rules while underwater remains a crucial divers’ disease), which was prepared by Konstantinos Sav- issue. vas, Professor of Microbiology and Hygiene at the Medical By examining the records of a Greek warship from the School of the University of Athens, on behalf of the Royal early 20th century, the study illustrates the lasting risk of Medical Council and addressed to the Ministry of Marine Af- inadequate or even inexistent safety among professional fairs (1904), and b) the data collected by Dr. Sfinis onboard divers in conditions of economic competition. The pressing the warship ‘Kriti’, which escorted Greek fishing vessels in need for work amidst the harsh economic crisis that tor- the Mediterranean. mented Greece in the late 19th century, coupled with com- Professor Konstantinos Savvas (1861–1929) was mercial competition, employers’ demands for quick profits, the founder of Hygiene, Epidemiology and Microbiology in and divers’ low earnings that forced them to exhaustive Greece (Fig. 1). Besides infectious diseases, Savvas took dives in order to earn more money, had taken their toll on up issues of occupational health and safety. The tragic safety. In addition, the absence of state controls embold- rates of morbidity and mortality among Greek sponge div-

* Dr. Costas Tsiamis, Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Greece, e-mail: [email protected]

28 www.intmarhealth.pl Costas Tsiamis et al., History of diving safety rules

periods of time soon gave rise to the problem of overfishing. The Ottoman Empire had prohibited sponge diving using diving suits up to three miles off its coast. During summer, the Greek fishing vessels collected sponges on the Tuni- sian coast, moving to Egypt and Cyprus in the winter. In the early 20th century, more than 500 fishing vessels were actively harvesting sponges around the Greek islands, of which 150 carried oxygen pumps and diving suits. Sponge trade was highly lucrative, while companies had established branches in Western Europe where sponges were sold as a luxury good. In light of protecting them from raids by other countries’ ships, fishing vessels grouped into fleets, each of which was escorted by a warship. The coexistence of fishing vessels within the same fleet (200–250 vessels) did not necessarily imply their cooperation, since the islands competed fiercely for the distribution of marine sites of sponge harvesting [4].

STUDIES ON DECOMPRESSION SICKNESS Human efforts to prolong their underwater stay on the seabed gradually led to the creation of new distinct scientific branches of Medicine. Alfred Léroy de Méricourt became interested in decompression sickness and published his relevant thesis titled ‘Considérations sur l’hygiène des pecheurs d’éponges’ in 1868, while Alphonse Gal travelled to Greece in order to complete his own thesis that was published in 1872, where he recorded the Figure 1. Professor Konstantinos Savvas (1861–1929) (Histori- symptoms of the disease by himself [5–7]. He gradually cal Archive of the Department of Microbiology, Medical School, National and Kapodistrian University of Athens) became more interested in the supply of compressed air to mines and caissons of underwater constructions, such as the construction of large bridges like the Eads Bridge in St. Louis and the Brooklyn Bridge in New York City, where ers prompted Savvas to examine the issue. To this end, he decompression sickness or ‘caisson disease’ was also ob- started collaborating with the officer Dr. Sfinis, who gave served. On account of that observation, Alphonse Jaminet him the data contained in the medical records from four (1871) and Andrew Smith (1873) — the doctors overseeing expeditions dated from the period 1900–1903 [1]. In an the construction of Eads Bridge and Brooklyn Bridge re- effort to fully comprehend the physiology of underwater spectively — published two studies describing the disease diving, Savvas travelled to the Diving Academy facilities of and their experiments [8, 9]. In 1878, Paul Bert laid the the Imperial Russian Navy in Kronstadt in 1903, whereas foundations of hyperbaric medicine in his monumental he also studied numerous educational dives on the coasts work ‘La Pression Barométrique rechearches de Physiologie of Finland [2, 3]. Expérimentale’ [10, 11]. Despite widespread dissent, it appears that the dangers SPONGE DIVING IN GREECE of the disease had been known in Greece at least since (19TH–20TH CENTURY) the 1860s, when the first diving suits were used by the Sponge diving constitutes a legendary chapter of the Dodecanesian sponge divers. In 1867, Auguste Denayrouze Greek naval history. Over the centuries, sponge diving tech- published a manual on the use of diving suits, which offered niques evolved from diving without equipment to diving clear and specific instructions to those who descended up suits. After the establishment of the modern nation state of to 50 metres: ‘Ascending very slowly, the diver can avoid Greece, the first diving suits were introduced in the Aegean abrupt transition to atmospheric pressure. Periodical stops islands — both those that were liberated and the ones that (during ascent) help to make decompression smooth’ [4]. remained under Ottoman control — in the first half of the Studies on decompression sickness were also conducted 19th century. The capability of staying underwater for longer in Greece. In 1881, I. Tetsis published his study titled ‘L’île

www.intmarhealth.pl 29 Int Marit Health 2020; 71, 1: 28–33 d’Hydra et les maladies des plongeurs’ in Paris, distin- long been inscribed in Greek historical consciousness. On guishing between four levels of the disease: temporary the other hand, the drama of mothers and wives of dead cerebral congestion, paraplegia, haemorrhage that may lead or handicapped divers has been an integral part of island to death, and comatose state that always leads to death [4]. societies [4]. Each ship was manned by 8–12 divers aged Of major importance was the study of K. Katsaras, who 19–45, many of whom came from continental Greece in studied 62 divers suffering from the disease [12]. search of easy profits but lacking familiarity with the marine environment. For instance, the records revealed that THE MEDICAL RECORDS numerous divers had formerly worked as farmers, shep- OF WARSHIP ‘KRITI’ herds, carpenters, builders, barbers, railroad employees or The warship accompanied the Greek fishing fleets in various other professions that were completely unrelated in four expeditions: 7 May – 20 October 1900, 12 May to marine life and the dangers of the sea. – 20 October 1901, 17 May –16 October 1902 and 15 May – 24 October 1903. The health records of divers SAFETY RULES who suffered from the disease between 1900 and 1903 The records of warship ‘Kriti’ illustrate that safety rules were handed to Savvas and highlighted various aspects and were essentially absent from diving. The Hellenic Navy em- risk factors of the disease. ployed no divers who would dive to such great depths, since their main mission rested in performing maintenance tasks WORKING CONDITIONS on the hulls of ships. This was the main reason why no casu- The problem of decompression sickness lay in the highly alties were recorded in the Navy, coupled with the rigorous problematic business model of the time and started long military standards that were strictly followed by its divers. before the expedition itself. In order to be able to equip Civilian divers, on the other hand, experienced a totally their ships, captains were forced to borrow heavily from the different situation. The whole process was outside state banks. They also borrowed capital from the private sector regulation and anyone could become a diver, even without with interests of 24% to 36%, which had to be repaid within training, while basic safety rules were absent from fishing 6 months, while their ships or even homes were put up as vessels whose equipment was outdated and dangerous. collateral for those loans. Moreover, it was lenders who The inspections of fishing vessels conducted by officers provided captains with the necessary equipment, usually and doctors revealed crucial violations in relation to their at very high prices. As a result, captains were already in- equipment, like diving suits lacking maintenance, helmets debted before they had even set sail and their only hope lacking lanterns or cables of communication with the ship, lay in harvesting large quantities of sponges. Any delays in oxygen pump pistons lubricated with animal fat that contam- their departure meant that divers had wasted their salaries, inated the air inside helmets, or pumps that channelled hot thus they too could only set their hopes on harvesting many air due to their poor maintenance. A notable effect of these sponges since they would accordingly get a share of the deficiencies was the case of the release and detachment profits. Captains were faced with pressing loans that gave of a diver’s helmet while working at a depth of 40 metres. rise to irrational demands for more and more dives, a reality Professional divers dived up to 6 times during their shift that proved to be a major risk factor for accidents. The cap- and usually worked at a depth of 45–60 metres, sometimes tains’ burden was passed on to the divers who, according reaching 80 metres. They ascended really fast and would to Savvas, ‘lost their freedom and became slaves of the ‘hurl at high speed and immediately remove their diving suit captain’. Similarly, the oral testimonies of captains indicate in order for the next diver to use it and for them to go to that they, in turn, were slaves of their lenders: ‘When you rest’. Each dive lasted 40–50 minutes: ‘On 27 June 1903, have borrowed a lot of money and mortgaged your house, a diver of the ship Evangelistria dived to 30 metres and you have to earn that money and the time is not enough. remained on the seabed for 50 minutes, then ascending Therefore, the people (divers) must ascend quickly’; ‘How fast and not smoothly. After one hour and a half, he dived many hours does the day need to have for me to be able again to the same depth and remained underwater for to do my job, to earn the money that is not mine, to pay the 45 minutes. One hour later he dived to 30 metres and bank, to pay the people?’ [4]. stayed for 35 minutes. When he ascended, he reported dizziness and lost his consciousness. As soon as he regained THE DIVERS’ PROFILE consciousness, he felt numbness on his limbs and was The profile of the proud diver and tragic hero who boldly unable to stand. Complete paralysis ensued…’ confronts real and mythical dangers in the great depths of A regretful finding rests in the testimonies of divers, who the sea and thoughtlessly spends all his money while on secretly entrusted them to the Navy officers. Some captains land, since any of his next trips might be his final one, has ignored divers’ signals for ascent, not allowing them to

30 www.intmarhealth.pl Costas Tsiamis et al., History of diving safety rules return to the ship or forcing them to dive again when they The presence of the warship and the lax controls did not considered the quantities of sponges they had harvested to have any effect on captains, since the legislative framework be insufficient. On the other hand, some operators of oxygen was essentially non-existent and the naval officers were pumps mentioned that divers themselves often ignored unable to intervene. On the other hand, many captains their signals in light of discovering hundreds of sponges, pulled away from the fleets and resumed their oppressive suffering from what they called ‘seabed drunkenness’ that behaviour towards divers. For instance, 60 divers working made them want to collect them all [4]. on the fishing vessels that had abandoned the fleet in 1901 The divers’ diet was satisfactory and included fish, meat died outside Benghazi in Libya. and legumes, while they had 2 to 4 meals a day. Pressure This situation changed during the last expedition of and tension, however, led to excessive smoking and alco- ‘Kriti’ in 1903, when the naval officers acquired extended hol consumption. Savvas considered the usual practice powers that allowed them to conduct sworn interrogations. of consuming an alcoholic drink in between dives to be This tactic scared the captains, who began to adhere to the burdensome for the divers’ overall health. In a time when newly-established safety rules of the Ministry of Marine the concept of risk factor was unclear, Savvas was able to Affairs. The interrogations carried out in 1903 revealed distinguish alcohol as a significant factor that could cause that — besides the three divers hospitalised aboard ‘Kriti’ accidents. who passed away — another 24 divers had also died in that same year. On the other hand, the officers were unable to DECOMPRESSION SICKNESS IN NUMBERS verify the worrying allegations of another 40 dead divers. In According to Savvas, Paul Bert had been informed that any case, contemporary estimates placed the total number 30 Greek divers died on average every year during the of Greek divers onboard the Greek shipping vessels during 1870s. The studies conducted by Greek doctors referred the last expedition of ‘Kriti’ at 900, of whom 100–150 to ten deaths per year but indicated equally high rates of either died or acquired some kind of disability. It should be disability. Between the years 1878–1900 it was estimated clarified that the failure to record the total number of deaths that approximately 100 divers had died while more than may have been due to the fact that some islands remained 800 were left paralysed. Unfortunately, there is no conclu- under Ottoman control and thus the Greek ships still carried sive and systematic data on the exact number of victims the Ottoman flag. As a result, the Greek authorities were per island. For instance, it has been reported that ‘more informed of accidents only when a captain contacted the than 15 died every summer’ in the Dodecanese during the Greek consulates in the Greek islands controlled by the 1870s. Russian Professor Karolus Flegel, a renowned and Ottomans. staunch objector of diving using a diving suit, pointed out that at least 800 divers had died from the island of Kalym- MEDICAL FINDINGS FROM THE RECORDS nos since the introduction of the diving suit, a number that Savvas’ report confirmed the aggravating factors for remains to be verified [4]. decompression sickness that were already mentioned in The records from the period 1900–1903, however, of- contemporary bibliography, namely diving depth, duration fered a more coherent picture of the prevailing situation. of stay on the seabed and number of consecutive dives. The The records of ‘Kriti’ included the number of patients, the disease was linked to the three stages of diving: increas- seriousness of their condition, as well as the number of ing pressure during descent, high atmospheric pressure those who did not survive. All patients were grouped into age while on the seabed and abrupt divers’ ascent. According groups, whereas the doctors also classified symptoms into to the records, decompression sickness appeared shortly ‘disorders of the central nervous system’, ‘heart disorders’ after ascent and removal of the helmet of the diving suit. and ‘lung disorders’. Particular attention was paid to paral- Divers suddenly felt malaise, dizziness and imbalance, ysis, which was categorised as ‘upper limb paresis’, ‘lower pain in the precordium that extended to the left shoulder limb paresis’, ‘hemiplegia’, ‘upper limb paralysis’, ‘lower limb and nape, headache, tinnitus, aphasia, thirst and burning paralysis’, ‘perfect lower limb paralysis’ and ‘paralysis of the in the epigastrium. whole body’. Over the 4-year period covered in the records, Divers presented shortness of breath for 30 minutes, a total of 936 divers were hospitalised, of whom 152 in seri- followed by faint and anaesthesia for 15 minutes. By the ous condition. Twenty one of these 152 patients passed away, time a diver regained consciousness, all symptoms had while those who survived developed some kind of disability. disappeared only to be replaced by symptoms of paralysis. Ages 21–35, especially 26–30 (46%), represented the age Over the next 4–8 hours, the unfortunate diver felt numb- spectrum that was mostly affected by decompression sickness throughout his body, losing his ability to move and ness. As far as the type of paralysis is concerned, paralysis experiencing paraesthesia in the upper and lower limbs. of the lower extremities was the most common. This situation resulted in hemiplegia, monoplegia or cervical

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Figure 2. Metal suit P-7 Neufeldt and Kuhnk in section. Glass- -slide from the lectures of Prof. Savvas on Divers’ Hygiene. (Prof. K. Savvas Collection, Historical Archive of the Department of Microbiology, Medical School, National and Kapodistrian Uni- versity of Athens) Figure 3. Test of P-7 Neufeldt and Kuhnk (France 1926). Glass -slide from the lectures of Prof. Savvas on Divers’ Hygiene. (Prof. K. Savvas Collection, Historical Archive of the Department of and head movement ability only. Over the next 3–5 days, Microbiology, Medical School, National and Kapodistrian Uni- versity of Athens) the diver experienced urinary retention that was followed by urinary incontinence. Upon his recovery, the patient was able to walk only with the help of a walking cane. the divers who oversaw the whole process. Upon returning from an expedition, the captain handed over the book to STATE INTERVENTION IN RESPONSE the port authorities for inspection. TO SAVVAS’ REPORT In turn, divers had to be healthy, that is, not suffer from Following the tragic conditions that came to light from cardiac, haematologic, urinary or nervous system diseases the data, the Ministry of Marine Affairs was called upon to (or rheumatic diseases, based on contemporary medical take immediate action at various levels. At that point, the perceptions), whereas dives had to be performed 3–4 hours influence of Professor Savvas’ prestige came into play, after consuming a meal. In addition, professional divers had definitely corroborated by his relationship with the royal to be aged 21–35, while the establishment of the School of family. Numerous of his proposals were eventually taken Divers was decided, where prospective divers would obtain into account and largely influenced the nature of the divers’ a diploma and basic first aid knowledge. profession. The safety rules that were introduced were designed in The first measure provided for keeping a book where line with those of the German Navy in 1898. This should not captains recorded all dives performed by the divers onboard come as a surprise, given that Prof. Savvas had received their ships. Each entry had to include the site, depth and further training in the Institute of Public Health of Berlin duration of a dive, along with the name of the diver and and was generally familiar with the German scientific way the signatures of the captain and two representatives of of thinking. Based on those criteria, the duration of under-

32 www.intmarhealth.pl Costas Tsiamis et al., History of diving safety rules water stay was defined as follows: 1 hour at 9–10 metres, to the health of professional divers from an educational per- 15 minutes at 23–25 metres, 10 minutes at 35–42 metres, spective, incorporating them in the lectures on hygiene that 5 minutes at 42–47 metres, 3 minutes at 47–50 metres he offered to his students at the Medical School (Figs. 2, 3). and 1 minute at 50–55 metres. As far as the other technical parameters were concerned, the rate of ascent was set at CONCLUSIONS 2 metres per minute, while oxygen pressure should not The history of Greek sponge divers in the early 20th exceed 5 atmospheres (atm). It was also determined that century represents a classic and timeless example of safety 3 months after their therapy, divers could start diving again rules violation arising from economic competition and hard- on the following terms: no more than 3 times a day, at depths ship. Lacking regulation and any form of state oversight, of 8–10 metres, remaining underwater for 15–30 minutes. professional sponge diving proved to be extremely deadly. A key development that originated from Savvas’ report Of course, that era was completely different from modern was the fact that divers were no longer unprotected, as times in relation to divers’ professionalism, safety rules employers were to be held accountable and subject to pun- and labour rights, since nowadays a strict legal framework ishment. Firstly, captains were now prohibited from coercing has been put in place to protect professional divers. The divers to multiple dives, whereas they had no right to ask prospect of exploitation, however, which leads to violations a diver to dive when the latter suffered from any disease. of the safety rules governing this high-risk profession un- Moreover, in the event of an accident, interrogations were der the pressure of competition, coupled with voluntary carried out and those deemed responsible were brought to or involuntary acceptance of such situations by the divers justice. In this context too, Savvas proposed that the laws themselves, poses a serious risk factor for accidents. On the of the German Criminal Code were put in place. Although other hand, the institutions entrusted with overseeing the a diver’s death would be regarded as negligent homicide, profession must always be alert and prepared, especially in the sentences ranged from heavy fines and seizure of the times of financial crisis when working conditions are subject ship to imprisonment for 3 months to 3 years. But Savvas to changes and pressures. left nothing to chance, as he took another aspect of the problem into account and provided for the establishment REFERENCES of a pension fund for divers, which was maintained through 1. Zotos P. Report from the African Coasts on sponge-divers. Athens 1904. employers’ contributions and offered financial assistance to 2. Diamantis A. History of the Military Medicine in Greece. Lege Artis, Athens: 122–124. the widows and orphans of deceased divers. Additionally, 3. Savvas K. Report on divers’ decompression sickness. Prophylactic a special framework was established that prevented lenders measures. Ministry of Maritime Affairs. Athens 1904:3-93. from imposing interest rates of more than 10%, thereby 4. Olympitou E. L’influence de la pêche aux éponges sur la société de relieving captains from the strain of repayment and fear Kalymnos aux 19e-20e s. Mnemon. 2010; 31: 247–266. of their ships being confiscated. As a result, captains’ be- 5. Alfred Léroy de Méricourt Hygiène des pêcheurs d’èponges. Ann Hyg Publ Med Leg. 1869; 31: 274–286. haviour towards the divers changed altogether. 6. Alphonse Gal Des dangers du travail dans l’air comprime et des In spite of scientific work, decrees, legislative efforts and moyens de les prévenir. Thèses de doctorat en medicine, Faculté public complaints, the concept of work-related accidents de medicine de Montpellier 1872. and the identification of the causes of death in sponge div- 7. Blatteau J, et al. É., Accidents de désaturation en milieu subaqu- ing remained controversial until the whole sector became atique: premières descriptions cliniques et hypotheses physiopath- ogéniques. Med Armees. 2015; 43(1): 49–60. obsolete in the aftermath of World War II. Even in the 1970s, 8. Péchon JCLe. De 1878 á 2006 — Travaux hyperbares en tunnels. divers demanded that their whole salaries were paid in J Soc Blol. 2006; 200(3): 265–272, doi: 10.1051/jbio:2006031. advance, on the grounds that they would likely never return 9. Butler WP. Caisson disease during the construction of the Eads and from the upcoming expedition [4]. Brooklyn Bridges: A review. Undersea Hyperb Med. 2004; 31(4): Being the most relevant experts, the doctors of the Hel- 445–459, indexed in Pubmed: 15686275. lenic Navy continued their research unabated. Two doctors 10. Bert P, Brocklehurst R. La pression barométrique : recherches de physiologie expérimentale /. Paris. 1878, doi: 10.5962/bhl.title.104929. who had been trained in Kronstadt promoted the adapta- 11. Rudolph G. [In memory of Paul Bert (1833-1886) and the develop- tion of the diving tactics of Greek sponge divers to new ment of high altitude physiology in Switzerland]. Gesnerus. 1993; standards, suggesting that they stayed on the seabed for 50 ( Pt 1-2): 79–95, indexed in Pubmed: 8365675. a brief period of time and ascended slowly [13, 14]. After 12. Katsaras K. Recherches cliniques et experimentales sur les ac- tackling the problem of decompression sickness, Professor cidents survenant par l’emploi du scaphandres. Arch de Neurol. 1890: 47–77. Savvas became involved in other sectors of public health 13. Livadas S. On the paralysis of the divers and the oxygen therapy. and focused on the major infectious diseases of the time. Athens 1905. Nevertheless, he continued to reflect on issues pertaining 14. Zografidis S. Contribution to the decompression sickness. Athens 1906.

www.intmarhealth.pl 33 Int Marit Health 2020; 71, 1: 34–41 10.5603/IMH.2020.0009 www.intmarhealth.pl REVIEW ARTICLE Copyright © 2020 PSMTTM ISSN 1641–9251 Mental health problems and suicide in the younger generation — implications for prevention in the Navy and merchant fleet

Vsevolod Rozanov

Saint-Petersburg State University, Saint-Petersburg, Russian Federation

Abstract Psychologists and psychiatrists worldwide are expressing concerns regarding the growing prevalence of mental health problems and the incidence of suicide in young adults. The reasons are seen in the extremely high tempo of social changes, information pressure, and values evolution in the younger generations, which are exposed to growing inequalities, loneliness and lack of social support. Poverty, social isolation, consumerism, hedonism, and unrealistic expectations of the future generate in the vulnerable part of the young adults inevitable frustrations, which give way to depression, anxiety, addictions, and suicide. This creates additional risks for the situation on board ships, both military and merchant, and requires greater efforts during pre-admission selection and in the course of the service or voyages. Suicides in the Navy are better registered than in the cargo fleet and are lower than in the same age and gender groups from the general population, and usually lower than in other types of forces. Data on suicides in the civilian maritime sector are less conclusive, but suggest it as a growing problem, especially considering stress on board. Recent studies revealed quite a lot of mental health problems in the merchant fleet crews, including depression, anxiety, and suicidal thoughts. Among the reasons such factor as “flag of convenience” strategy that implies lower standards, recruiting of the less trained and lower-paid workforce, multinational and multilanguage rotating crews, higher workload and stress and insufficient level of the pre-employment medical examination are mentioned. Recent trends in the mental health of the youth demand higher awareness both in the military ships and in the merchant fleet. We consider that more education and training aimed at mental health problems identification and stress-resilience promotion are needed both for the military and civilian staff on board. Better education of the whole personnel and “healthy ship” approach (better recognition of the crew members’ needs, attention to mental health problems, nutrition, physical activity, etc.) may be applied both for the Navy and merchant fleet. (Int Marit Health 2020; 71, 1: 34–41) Key words: mental health problems, suicides, young adults, suicide prevention, Navy, merchant fleet

INTRODUCTION health in young adults. According to the most recent The world has changed a lot for the last decades, and epidemiological studies, the prevalence of any disorder there is a general feeling that today unprecedented global in younger people is about 20% for the last year [1–3]. forces are shaping the health and wellbeing of the larg- Among the disorders, there are anxiety, depression, addic- est generation of 10 to 24-year-olds (the so-called iGen, tions, hyperactivity, psychosomatic symptoms, personality or Generation Z) in human history. Specialists in mental disorders, behavioural problems, and phobias. Studies health promotion and psychiatrists worldwide are express- and reviews provide evidence that in recent decades the ing concerns regarding the growth of the problems of mental prevalence of anxiety, depression and substance abuse

Prof. Vsevolod Rozanov, MD, PhD, Saint-Petersburg State University, Makarova embankment, 6, 199034 Saint-Petersburg, Russian Federation, * e-mail: [email protected]

34 www.intmarhealth.pl Vsevolod Rozanov, Mental health and suicide — prevention in the Navy in adolescents and young adults has increased most of (US) has revealed that while suicide rates for soldiers who all [4–6]. Moreover, birth cohorts comparisons testify that served in Iraq and Afghanistan more than doubled from some personality traits, for instance, neuroticism and clini- 2004 to 2009 to more than 30 suicides per 100,000, the cal scales of MMPI, have grown substantially too [7]. Mental trend among those who were never deployed nearly tripled health problems are more pronounced in youngsters from to between 25 and 30 suicides per 100,000. Rates for lower social-economic strata, though they are inherent to all similar age and sex civilians remained almost steady at social classes. Comorbidity of disorders, as well as general 19 suicides per 100,000 during this time. These results, and mental health poor rating, is associated with suicidal as the authors say, “argues indirectly against the view that thoughts and more serious manifestations of suicidal be- exposure to combat-related trauma is the exclusive cause haviour — attempted and completed suicide [3]. of the increase in Army suicides”, pointing to pre-existing Analysis of the situation with suicides in adolescents problems among modern youth [11]. and young adults shows that suicides in this contingent are Another part of this massive study pointed out that one in growing worldwide [8, 9]. The peak in the most economically four soldiers in the army appears to suffer from at least one developed countries has passed, but even in the countries, psychiatric disorder and one in ten has multiple disorders. where national suicide prevention programmes were im- Most importantly — about a third of soldiers who attempted plemented, suicide levels did not drop substantially. In the suicide had mental disorders that developed before they 90s a rise in suicide rates in young adults has been very joined the army: an indication of the general shift towards typical to Britain, Australia, and Western America, then the mental ill-health in young people and a warning that more focus shifted to post-soviet countries, and recently have professional efforts are needed while screening for mental touched Latin America, China, Korea and other countries of health problems among recruits [12]. The authors discuss South-East Asia [9, 10]. It may be hypothesized that recent that the rise in suicides and diagnoses was the result of two decades rise in rates in the countries and communities with recent US Army trends aimed to recruit or retain personnel. traditional cultures are the results of the pressure of the One trend was the liberalisation of screening rules and en- postmodernism that promotes very liberal attitudes to life rolment of recruits with poor education or conduct records, and death. the other was the practice of forcing soldiers to remain in service beyond their enlistment [11, 12]. The study did not MILITARY ENVIRONMENT AS A MODEL directly confirm the role of these practices, but in a more FOR A MERCHANT FLEET recent article dedicated to recruitment problems Mark Perry Young soldiers constitute the majority of personnel in directly points that efforts to increase military size in US are conscription armies, many contracting specialists in the hampered by poor records of potential recruits, who are Navy are also young adults who have just graduated from undereducated, often obese and with criminal records — the military colleges or high schools. No surprise that when trend that implies also many mental health problems [13]. the time comes for the service they may ‘import’ their risks The situation in different armies and different types of to the military environment. This raises several important forces may vary. The above-mentioned study may depict questions: 1) how military forces can protect themselves specific features inherent to the US Army. On the other hand, from drafting personalities with hidden suicidal tendencies; military psychologists and psychiatrists from different parts 2) how to prevent exacerbation of mental health problems of the world are expressing the same concerns and advo- in the stressful military environment, and 3) what can be cate more efforts during selection and more testing before done to promote mental health and stress-resilience of the conscription or signing the contract with a serviceman, both staff. One of the relevant questions is also if the knowledge in the Army and the Navy. This is a questionable issue, in accumulated within the military and the Navy in particular some armies, a lot of attention is paid to psychological test- may be extended to civilian maritime sector given the unify- ing before enrolment, while in others screening for mental ing character of marine occupation with its’ organisational health is considered useless and the focus is shifted on and psychological peculiarities. performance and hardiness of the serviceman [14–16]. Suicides in the military may have the same risk factors as in the civilian population, i.e. mental disorder, life stress SUICIDES IN THE NAVY and trauma, alcohol and drugs abuse, frustrations, financial — ARE THERE PECULIARITIES? and legal problems, etc. Speaking about specific factors Recently, we have tried to outline some common fea- in the military settings, it was long supposed that combat tures of suicide within the military environment [17]. The exposure and traumatic experiences may be main additional following factors may be associated with an increased risk reasons for mental health problems and suicides. Never- of suicide in the military context: 1) the loss of or lack of theless, one of the recent studies from the United States personal freedom experienced by people entering rather

www.intmarhealth.pl 35 Int Marit Health 2020; 71, 1: 34–41 closed and authoritarian system; 2) the masculine culture the same age and sex group in the general UK population; in many military communities, which may leave little room however, in the recent decades rates in the military are for self-disclosure and peer support; 3) the risk for personal below the corresponding civilian age and sex groups. traumatic stress exposure and subsequent traumatic stress Suicide rates vary significantly from country to country, reactions; 4) the easy access to firearms; 5) the military life- while suicide rates in the military (though usually substantial- style with frequent relocations and the break-up of support- ly lower) may be ranked in the same order, which may depict ive social structures; 6) during profound changes in social cultural, religious and other nationally resistant peculiarities structures, when downsizing or reorganizing processes in [17]. On the other hand, time change in the civilian and the armed forces take place; and 7) the danger of suicide military environments may be different. As an example, in contagion and clustering of suicides in military units [17]. the former USSR Navy, the time-course changes of suicide These specific military environment risk factors may act rates differed distinctly from the general population: while together with risk factors inherent to the general population in the whole USSR there was lowering of suicides in 1986 (belonging to a vulnerable demographic group, chronic life (preventive effect of the ‘perestroika’ — democratisation stress, lack of social support, dysfunctional relations, prior and liberalisation in the country), in the Navy there was suicide attempt, mental health problems, etc.). Neverthe- a rise in the proportion of suicides in general death structure less, suicide rates in military populations remain, in most during the period 1986 to 1995 (period of serious economic cases, lower than in the civilian population of men of the problems, fleet downsizing, lowering of the prestige of the same age. This could be attributed to the existence of pro- marine professions). Only from 1998 to 2000 the percent- tective factors that may counterbalance the situation: 1) the age of suicides started to diminish. In the Navy, two-thirds military is a highly organized structure and if the problem is of all suicides occurred among conscripted personnel during well understood by commanders, prevention programmes their first year of service. In 65% of the cases, the method of may be implemented in a prompt and effective way; 2) there suicide was hanging, 20% firearms, 5.5% intoxications, 5.2% is a preliminary and ongoing medical control of those who self-cutting, 2.2% jumping and finally, 1.8% drowning [21]. are dealing with weapons and certain psychiatric conditions Though suicide rates in the Navy are low, the impact of may be recognised early on; 3) special prevention measures such a tragic event on the battleship may be rather high may be organized and special means of reporting may be and may induce severe psychological trauma in the crew, implemented that provide quick identification of suicidal especially in the immediate commander-in-charge, or in the persons along with their referral to specialists; 4) the military closest friends. The whole crew may be also psychologically can discharge those with suicidal ideations or actions to impacted, depending on the situation. Given this, every case reduce suicide risk; 5) every case of completed or attempted must be thoroughly investigated and a report should be suicide may be thoroughly investigated producing important developed according to the existing rules in every Navy, but information for further prevention models [17]. also a debriefing should be provided for the crew. It applies Navy personnel in all countries that have fleets belongs also to cases when suicide of the crew member happened to the most educated and trained due to high demands exist- ashore but became known to the crew. ing in the modern battleships and submarines. No surprise that suicides in the Navy are usually rather low. For instance, COMPARISONS WITH THE CARGO FLEET regular suicide statistics from the US military forces testify The situation in the Navy and cargo fleet definitely has that suicide rates in the Navy are the lowest, followed by many similarities, especially taking into account conditions the Air Force, Army and Marine Corps [18]. Micklewright on the ships, noise, electromagnetic fields, ship movements, reported on deliberate self-harm in personnel of the Royal stressful shift work, isolation, lack of social support, remote- Navy [19] and concluded that these acts should be viewed ness from the family, etc. Moreover, if comparing with other in the context of the environment that often imposes psy- occupations, organisational and psychological factors on chological, emotional and social pressures on servicemen. merchant ships are more close to the military environment, In the United Kingdom (UK), detailed information on suicide with high level of subordination, responsibility and crew co- in the regular Armed Forces is published by the Defence hesion. Both in the Navy and merchant ships high demands Analytical Services Agency (DASA). For the 23 years from are imposed on the staff in relation to withstanding austere 1984 to 2006, suicide rates in the Army ranged from 12 to and dangerous conditions of seafaring, probable fight for 20 per 100,000, suicide rates in the Naval service ranged the buoyancy and survivability of the ship and during rescue from 6 to 14, and from 3 to 15 per 100,000 in the Royal operations. Air Force (RAF), most recent figures (2018) are 10 for the The merchant fleet, like the Navy service, recruits young Army, 8 for the Navy and 4 per 100,000 for RAF [20]. Suicide educated specialists from corresponding educational insti- rates in the young age military in the 90s exceeded rates of tutions, where students are the same representatives of

36 www.intmarhealth.pl Vsevolod Rozanov, Mental health and suicide — prevention in the Navy generation Z (Digital Natives) with their typical academic were expressed regarding stress on the working place on stress, loneliness in the social media and lack of social board merchant ships, including unsatisfactory working con- support. They definitely benefit from their advanced digital ditions and psychological strain, the situation with mental competency, like managing many tasks at once and high health and suicide was not perceived as being worse than productivity based on abilities of surfing through web, but in other sectors of economics. also may import onboard mental health problems inherent Another part of studies, especially the most recent ones, to this generation, including anxiety, depressive thoughts, on the contrary, has reported about growing problems. For hyperactivity and impulsivity. Less-educated crew members instance, studies have found that from 6% to 35% of sea- are even at a bigger risk, especially under current recruiting farers knew colleagues who considered suicide and pointed circumstances. This issue is worth special attention. that stress, anxiety, depression, and sleep disturbances are Economic factors that are prevailing recently in the cargo serious risk factors among seafarers [24]. Several most re- fleet seem to produce more mental health risks for workers cent surveys have confirmed that stress, job strain, and high and employees on board. Globalisation and flags of conve- work demands are directly related to mental health problems nience companies’ practices of last decades (lower stan- among engine officers [29, 30] and that seafarers’ lifestyles dards, economic pressure, minimal crews’ size, recruitment on board (smoking, sedentary behaviour, unhealthy food strategies oriented on lower-paid staff, etc.) changed the and lack of physical exercise) may be main contributors to global seafarers’ trade market, introduced shortened mul- lower well-being [31, 32]. It coincides with the conclusions tilingual multinational rotating crews, eliminated medical of the most comprehensive report published up-to-date [24]. doctors from the crews, gradually induced higher work-load What may be the reasons for this negative development and caused gaps in seafarers’ rights protection [22]. All this in the most recent years? Several explanations may be sug- satisfies interests of shipping companies’ owners, but also gested, among them better understanding of the problem provides a fertile ground for conflicts, psycho-social stress, by those in charge for seafarers health and well-being and a mental health problems, alienation, and impaired social shift towards direct questioning about mental health issues support on board. In confirmation, recent study on seafarers and suicidal thoughts (possibly avoided previously due to mental health, based on structured interviewing of 1572 stigmatisation), which may produce more symptoms. On merchant ships crew members of different nationalities the other hand one cannot exclude real worsening of the have revealed that 25% of respondents may be qualified as situation, especially when the socio-economic context is having depression higher than in other working and general analysed. Some authors point on already mentioned fast populations, 17% may be defined as having heightened technological and organisational changes and the increased anxiety, while 20% admitted rare and 2% — constant suicidal pressure for economic profitability that may contribute to thoughts [23]. The working environment has been identi- lower well-being, for example through role conflicts or per- fied as the main determinant of seafarers’ mental health ceived stress on board [30]. On the other hand, one may problems, especially such factors as non-caring company agree with the opinion that the complexities of mental health culture, violence at work and low job satisfaction. Seafarers problems identification in multinational and multilingual from the Philippines and Eastern Europe appeared to be crews may be the reason [24]. The topic of mental health the main victims of workplace violence [23]. and suicide remains a strong taboo in many cultures, while Previously in a review of the problems of mental health modern trends (multinational crews, high workload, the short and suicide among merchant fleet crews authors have ship turns, work stress, job insecurity, etc.) elevate the risk of outlined two conflicting tendencies that are reflected in the suicides. The problem becomes exposed only during direct literature reviewed before 2017 [24]. One part of studies, questioning within the context of special studies and surveys. especially older ones, covering period of the second half of Therefore, the issue of mental health and suicides in the the previous century, give an impression of a rather safe merchant fleet crews warrants further research and analysis. picture — pretty low rates of confirmed suicides (1.3–2.2 Another systemic problem is seafarers’ medical exam- per 100,000) [25, 26], moderate effects of the burn-out inations and health assessments — the system is still fo- syndrome [27], not much complaints on fatigue and dis- cused on cardiovascular health, while mental health issues, tress in the self-reports, higher satisfaction with work and especially depression and suicide risk remain obscure, low repatriation rate for mental health reasons [26]. In the either due to low attention from the medical authorities Polish seamen and fishermen for 40 years from 1960 to and complexities of objective evaluation, or due to work- 1999 there were identified 51 suicides, which is quite low ers’ dissimulation of symptoms, which is easy to perform. in terms of rates given that the population surveyed was Moreover, recruiting crews from low-income countries, which 25,000 per year, even if part of cases remained hidden or is the dominating trend in modern sea trade, often leads attributed to other reasons [28]. Though many concerns to falsification of medical certificates [24]. Therefore, it

www.intmarhealth.pl 37 Int Marit Health 2020; 71, 1: 34–41 may be noticed, that situation in the cargo fleet has some promotes violence, envy, consumerism, fear and social similarities with the tendencies noticed by US military psy- isolation. Other factors that may be named are the weak- chiatrists mentioned above [11, 12] and that not enough ening of the role of the traditional family, lack of social attention to mental health problems as well as objective support, poor parenting, and vague life perspectives [3]. difficulties in assessment of suicide risk may contribute to All this means a higher level of psychosocial stress, which problems in the merchant fleet, while situation in the Navy is accompanied by anxiety, sleep disturbances, symptoms looks more definite. of depression, reduced performance, or tiredness. Studies It is also important to look at suicide on board in the evaluate that more than 40% of youngsters have a feeling context of risky behaviours, in terms of ‘human factor’ and of being stressed, and a huge majority of them report they accident analysis [33]. Conditions in which personnel live are feeling tiredness in the morning. There are also facts and work may influence physical and mental health and be- that academic environment and social media in many cases haviours, both healthy and unhealthy. People’s behaviours turns into a source of additional distress and anxiety [6]. and unconscious gestures or motives can be important fac- Such a situation is a reason for serious concerns, es- tors leading to a variety of accidents, from minor traumas to pecially taking into account that early disturbances may major accidents and deaths. Some genetic factors may be have an impact on the whole life. Adolescence and early predisposing to risky behaviours while genes-environments adulthood are transitional periods when individuals are covariations may lead to self-selection into risky environ- particularly sensitive to environmental inputs. Behaviours ments. This may be an additional mechanism through which initiated during adolescence, such as substance use, high- some individuals may carry their risks with them on board. risk sexual behaviour, and risky driving, contribute to poor Another question is how life stress, both in the early periods health outcomes and mortality during later life. Young adults of life, and further in the working career can exacerbate fare worse than adolescents in many areas, with rates of these risks and lead to suicidal behaviour, and how these motor vehicle deaths, homicide, substance use, sexually types of stress interact [10]. transmitted infections, and mental health problems peak- Many interdisciplinary studies are needed to understand ing during young adulthood. Adolescents and young adults better stress-vulnerability and resilience in young people altogether seem to have a higher level of certain disorders seeking occupation associated with the sea and to develop than older adults; moreover, about 40–50% of those who more predictive tests to prevent those at risk from entering have had mental health problems in adolescence may have the occupation. It may have a value in the prevention of the same or different problems as being adults [5, 34]. suicides among seafarers, both in the Navy and in cargo Another important factor is related to meanings and fleet. As to the Navy, though the military system is much values, and how they are perceived by young people in the more organised and disciplined, some individuals may be society of post-modern. Recent sociological and psycho- seeking additional sensations and stressful experiences, logical surveys give evidence, that for several last decades which can contribute to mental health problems and sui- American college students much more often mentioned as cide risk. Recent advances in genomic studies and rapid “important” such life goal of “being very well off financially” accumulation of reference data may provide more objective instead of “developing a meaningful philosophy of life”. tests for suicidality in the future, which may be used in con- Meaning in life declined in importance by almost half during junction with psychological testing and psychophysiological the 1970s and 1980s, while money and success almost evaluations of stress-vulnerability and resilience. doubled to become the highest-rated goal, and trends have remained relatively stable since [35, 36]. In most recent EXPLANATIONS OF YOUTH decades the same shift is seen in the post-soviet space, MENTAL HEALTH PROBLEMS India, and China [37]. The growing role of individualism One of the most important questions is why above men- and personal success in opposition to collectivism and so- tioned negative tendencies in mental health and suicides in cial cohesion, growth of hedonism, pragmatism and moral young adults became so visible in recent decades. Explana- relativism may be the result of the aggressive propagation tory factors for this phenomenon include quite fundamental of these values by mass media [3]. features of modern societies, which go beyond inequality and disadvantage. Such factors may be mentioned as mod- IMPLICATIONS FOR THE NAVY AND ern lifestyles, social and moral conditions associated with MERCHANT FLEET — BUILDING high competitiveness, a high value of personal success RESILIENCE AND RAISING AWARENESS and unrealistic expectations promoted in young people by Suicide prevention is a mental health promotion. This the social environment and mass media. The increasing formula becomes more and more popular among suici- influence of mass media and modern information flows dologists, psychiatrists and mental health providers. The

38 www.intmarhealth.pl Vsevolod Rozanov, Mental health and suicide — prevention in the Navy essence of the strategy that lays behind it is that we are ficult conditions, ship movements, austere meteorological focusing not only on prevention itself, which implies the conditions, complicated technical equipment, working in identification of risk groups and organising interventions, isolated groups, functioning within a limited space, noise, but addressing wider issues of promotion of resilience and vibration, and electromagnetic waves are the factors pro- positive functioning in wider populations. This paradigm is ducing chronic stress. The authors conclude that service on based on the concept of mental health, which is a complex Navy ships requires certain psychophysical qualities and, non-psychiatric culturally sensitive phenomenon. Modern most important, resilience to stress. They advocate proper understanding of mental health includes such factors selection among the candidates based on psychiatric and as emotions, cognition, social functioning, and sense of psychological counselling for military and medical jurispru- meaning, purpose in life. It is based on subjective well-be- dence, as well as better training for doctors and specialists ing, self-efficacy, autonomy, coping skills, the desire for in psycho-prophylaxis of military units in the field of mental self-development and social cohesion. So being mentally hygiene [40]. In the civilian sector it may be transformed healthy is something that is far beyond having no mental into appeal for better training for general practitioners and disturbance [38]. members of special medical-psychological expert groups The complexity of the tasks in the modern Navy and involved in crew members medical examinations. merchant fleet means that the cognitive functioning and Resilience to stress is an extremely important feature for psychological stability of the staff, from the lowest to the the Navy personnel, as well as merchant crews’ members. highest level, is crucial. It imposes increased demands on According to existing views, it may be both a predisposition the conscripts, cadets and other specialists, especially in and a trained quality. Studies trying to measure biological, the submarines, deep see ships and highly technological psychological, cognitive, behavioural, emotional and spiri- specialised ships. Young people are still joining Navy or tual dimensions of resilience have revealed that regulation merchant fleet to “see the world”, but in many cases, this of fear and anxiety, impulse control and prosocial behaviour does not happen, instead they are working under stress in may be very important factors. Evaluation of successful ser- front of the computers, being exposed to the same factors vicemen has identified optimism, altruism, moral principles, as all modern youth, plus inevitable stressful factors of humour, spirituality, goals in life and constant training as the ship environment. All this means new challenges for main factors of resilience [41]. There is also a great body of the Navy in terms of maintaining high morale, motivation, research proving that resilience to stress is the result of the concentration and cognitive performance of the personnel. personality development, which implies interventions from Given specific conditions in the Navy (remoteness, stress- rather early childhood, for instance, exposure to mild stress ful environments, high workload, shift work, monotony, sometimes referred as stress-inoculation [42]. Because of high responsibility, etc.) there are higher demands to the this modern approaches of selection of the staff should stress-resilience and emotional status of any serviceman. pay more attention to all periods of life of the candidate, During the missions, more specific combat-related stress- including early ones. Modern studies of genetics and epi- ful factors may appear that may lead to acute operational genetics of stress and resilience may soon shed light on stress, which in a part of the personnel can over time turn intrinsic mechanisms of this phenomenon and possibly into long-lasting post-traumatic stress disorder. This can may produce a set of more objective predictors that may be also applied to the merchant ship’s crews so far as be assessed before the enrolment of the serviceman or some of them are exposed to such risks as modern piracy a civilian seafarer [10]. making the atmosphere very close to the military situation, In addition to the better and more focused selection when concerns and fears about possible attack constitute of the staff, one of the issues is improving help-seeking additional stress. behaviours by young adults in cases of psychological cri- Many authors in military psychiatry and psychology sis. Military (and Navy in particular) culture may become as well as in occupational psychology have formulated a barrier for help-seeking when first signs of mental health important principles of medico-psychological aid, prophy- disturbance or suicidal crisis emerge, thus a policy should laxis and rehabilitation measures aimed to prevent de- be developed that may help to overcome this obstacle. This ferred mental health disturbances and suicides. In some is absolutely true for merchant ships crews as well, so far as countries, special programs for the Navy are developed, masculine culture is inherent to the maritime profession in or special psychopathology services are created [39, 40]. general. Multicultural and multilingual cargo ship crews in In a recent article from Poland, authors are stating that this respect may exert additional problems due to restricted advanced technology on modern ships puts high demands communication and inability of crew members and officers on operators in terms of psychophysical characteristics, to notice depression or exacerbation of any other disorder, mental stability, and cognitive performance. Sailing in dif- except of course most severe ones. Studies also suggest

www.intmarhealth.pl 39 Int Marit Health 2020; 71, 1: 34–41 that improving mental health literacy, reducing stigma, and officers and staff will better understand mental health de- enhancing the desire of young people for self-reliance may terminants. It should be promoted within the whole marine have a positive effect. Much depends also on life goals, educational system, both military and civilian, starting from meaning in life and self-determination, which is a deep cadets’ education. feeling, also depending on the prestige of the seafarers’ profession. REFERENCES Another important practical goal is better training of the 1. Belfer ML. Child and adolescent mental disorders: the magnitude personnel, from officers to sailors. In the Navy it may be an of the problem across the globe. J Child Psychol Psychiatry. 2008; additional task for the medical doctor on board [43]. 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www.intmarhealth.pl 41 Int Marit Health 2020; 71, 1: 42–45 10.5603/IMH.2020.0010 www.intmarhealth.pl CASE REPORT Copyright © 2020 PSMTTM ISSN 1641–9251 A cruise ship emergency medical evacuation triggered by handheld ultrasound findings and directed by tele-ultrasound

Keith S. Boniface1 , Neal Sikka1 , Nicholas Page, Asi Peretz, Hamid Shokoohi1, 2

1The George Washington University, Washington, DC, United States 2Massachusetts General Hospital, Boston, MA, United States

Abstract Cruise ships travel far from shoreside medical care and present a unique austere medical environment. For the cruise ship physician, decisions regarding emergency medical evacuation can be challenging. In the event that a passenger or crew member becomes seriously ill or is injured, the use of point-of-care ultrasound may assist in clarifying the diagnosis and stratifying the risk of a delayed care, and at times expedite an emergent medical evacuation. In this report we present the first case reported in the literature of an emergency medical evacuation from a cruise ship triggered by handheld ultrasound. A point-of-care ultrasound performed by a trained cruise ship physician, reviewed by a remote telemedical consultant with experience in point-of-care ultrasound, identified an ectopic pregnancy with intraabdominal free fluid in a young female patient with abdominal pain and expedited emergent helicopter evacuation from a cruise ship to a shoreside facility, where she immediately underwent successful surgery. The case highlights a medical evacuation that was accurately triggered by utilising a handheld ultrasound and successfully directed via a tele-ultrasound consultation. American College of Emergency Physicians (ACEP) health care guidelines for cruise ship medical facilities should be updated to include guidelines for point-of-care ultrasound, including training and telemedical support. (Int Marit Health 2020; 71, 1: 42–45) Key words: cruise ship medical evacuation, point-of-care ultrasound, ectopic pregnancy, tele-ultrasound

INTRODUCTION passengers and crew who become ill or injured while at sea The cruise industry estimates that 28.5 million passengers receive the best care possible in the austere maritime envi- took part in a cruise in 2018 — an increase of 7% from the ronment. On board, patients are cared for by the physicians previous year — for an average of 7 days [1]. This number and nurses of the ship’s medical centre, and the vast majority can only be expected to grow, as over 120 new ships are on of these patients are managed on board until resolution or order at shipyards around the world with an average capacity until the next scheduled port call. Rarely, when patient’s needs of over 2000 passengers, as well as crew members [2]. It exceed onboard capabilities, a diversion or emergent medical is inevitable that some passengers and crew members will evacuation is required. Decision on an emergency medical become seriously ill or injured while at sea, at times far away evacuation is one of the most complex decisions the cruise from shoreside medical facilities. Medical care aboard cruise ship physician has to make. Often, these decisions are under- ships is guided by American College of Emergency Physicians taken with incomplete data due to the limitations of diagnostic (ACEP) Section of Cruise Medicine’s Guidelines [3]. The guide- testing on board. Increasing diagnostic certainty can help line makes recommendations for training of physicians and the physician make the decision to divert a ship or evacuate nurses, medications, and equipment on board to ensure that a patient with more accuracy and greater confidence.

Keith S. Boniface, Professor of Emergency Medicine, The George Washington University, 2120 L Street NW, Suite 450, 20037 Washington, DC, United States, * e-mail: [email protected]

42 www.intmarhealth.pl Keith S. Boniface et al., Cruise ship ectopic pregnancy ultrasound

In recent years, point-of-care ultrasound (POCUS) performed by clinicians at the bedside has transformed diag- nostics in emergency medicine [4]. At George Washington University, we operate a not-for-profit academic maritime medical advisory service. Our Maritime Medical Access telemedicine group, along with ultrasound faculty, have provided assistance to a cruise line through the acquisition of ultrasound equipment, development of POCUS protocols, training of physicians and nurses in POCUS, and tele- -ultrasound support and interpretation after deployment of ultrasound equipment. We present a case where ultrasound led to a dramatic shift in a patient’s care and prompted helicopter evacuation. This case highlights a successful medical evacuation that was accurately triggered by utilising a handheld ultrasound and successfully directed via a tele-ultrasound practice.

CASE REPORT A 25-year-old female crewmember presented to the ship’s medical centre at 16:35 hours on a sea complaining of abdominal pain for 1 day. The pain had been of varying intensity but was now 10 out of 10 in severity. Her pain was more prominent in the right lower quadrant. There was no reported vaginal bleeding or discharge. Vital signs were normal, and the patient was afebrile. Examination was Figure 1. Transabdominal pelvic ultrasound image from a 23-year significant for a soft abdomen, with positive tenderness -old 8-week pregnant crewmember. Transverse view shows empty uterus (U) surrounded by anechoic free fluid (arrow), with and voluntary guarding of the right lower quadrant. Absent visualised gestational sac (GS) and foetal pole to the right adnexa were rebound tenderness or signs of an acute abdomen. encircled by hyperechoic decidual ring The remainder of her examination was normal. Pelvic examination was deferred. Laboratory evaluation was significant for a white blood The vessel was at sea, with the next port call scheduled cell count of 14 × 103 per mcl, a haematocrit of 29.7%, for the following morning at 08:00. As the next port had platelets of 247 × 103 per mcl, a C-reactive protein lev- no surgical facilities, the decision was made to coordinate el of < 5 mg/L, and normal renal function and electro- a helicopter evacuation with the United States Coast Guard. lytes. A urine pregnancy test was performed that indicated The evacuation was initiated by 18:31. At the point of evac- a new diagnosis of pregnancy; a urinalysis was normal. Last uation, she had become tachycardic and hypotensive, con- menstrual period dating placed the pregnancy at 8 weeks sistent with a clinical presentation of early haemorrhagic 3 days gestation. shock. After coordination with the receiving institution, she Considering a wide range of important differential diag- was flown directly to a shoreside hospital, where the diagnoses including ectopic pregnancy, ovarian torsion, ruptured nosis of ruptured ectopic pregnancy and haemoperitoneum ovarian cyst, and appendicitis, a transabdominal pelvic was confirmed. She was transferred to the operating room ultrasound was performed by the cruise ship physician and underwent an emergent laparoscopic salpingectomy. utilising a handheld ultrasound. With the finding suggestive of a ruptured ectopic pregnancy, the shoreside telemedicine DISCUSSION team was consulted and images were transferred for review This is the first case that we have identified in the med- by the shoreside telemedicine team including an emergency ical or maritime literature where ultrasound performed by physician with tele-ultrasound experience. The ultrasound the onboard cruise ship staff led to a successful emergency revealed a uterus empty of a gestational sac, or any signs evacuation of a patient with life threatening clinical condi- of intrauterine pregnancy including a yolk sac or foetal pole tion, resulting in expeditious surgical management. Cruise (Fig. 1). In addition, the ultrasound demonstrated the pres- lines almost without exception prohibit pregnant women ence of a complex cystic mass in the adnexa (Fig. 2), and who will be in their 24th week of gestation at any point free intraperitoneal fluid in the right upper quadrant (Fig. 3). during the cruise, limiting potential medical complications

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Figure 2. Transabdominal pelvic ultrasound image from a 23-year Figure 3. Transabdominal pelvic ultrasound image from a 23-year -old 8-week pregnant crewmember. Sagittal view shows empty -old 8-week pregnant crewmember. Right upper quadrant view uterus (U) with gestational sac (GS) and foetal pole can be seen shows free intraperitoneal fluid (FF) in Morison’s pouch; L — liver; in adjacent right adnexa. A thin rim of free fluid is noted around K — right kidney the fundus of the uterus; B — bladder for patients with viable pregnancies [5]. Ectopic pregnan- Ultrasound equipment has evolved rapidly over the cies often present during first and early second trimester, past two decades, with large radiology cart-based systems however, and therefore are to be found in the cruising being replaced at the point of care by smaller cart-based population of pregnant women. A high index of suspicion machines, laptop-sized machines, and truly handheld ultra- for ruptured ectopic pregnancy is required, and ultrasound sounds that can connect to a tablet or smart phone. Factors findings can help to increase clinical suspicion of ruptured that should influence decisions about which machine to buy ectopic pregnancy (free peritoneal fluid, empty intrauterine include what type of examinations will be done, whether cavity, adnexal mass) as well as haemodynamic instabili- superficial (e.g. for vascular access and foreign body imag- ty because of the resultant haemoperitoneum. Presence ing) and deep structures (e.g. transabdominal obstetrical, of free fluid in Morison’s pouch may predict the need for cardiac, and abdominal imaging) will both be imaged (as operative management [6]. Ruptured ectopic pregnancy this requires two probes for vast majority of manufacturers), combines two limitations of care found in the maritime cost, plan for storage of images, and image quality. medicine environment — absent surgical capabilities, and Protocols for ultrasound imaging should be focused lack of blood products. on clinically important diagnoses that impact the course Point-of-care ultrasound is a skill that can be very helpful of treatment for patients aboard ships. Identification of to the cruise medicine physician, and a review of the ACEP’ surgical emergencies such as ruptured ectopic pregnancy emergency ultrasound guidelines point to several indica- and intraperitoneal bleeding is paramount, as it can take tions useful to physicians working in cruise medicine who critical time to get a patient at sea transferred to the care face cases of shock, vaginal bleeding, dyspnoea, abdominal of a surgeon. Lung and cardiac ultrasound can expedite the pain, chest pain, change in vision, and swollen extremities, diagnosis of patients with congestive heart failure, pneumo- all syndromes where a diagnosis can be made easily with nia, right heart strain, and pericardial effusion, leading to POCUS [4]. earlier administration of the correct therapy for patients with

44 www.intmarhealth.pl Keith S. Boniface et al., Cruise ship ectopic pregnancy ultrasound unclear causes of hypotension or dyspnoea. Normal findings directed via tele-ultrasound consultation. The ultrasound can be reassuring or help to rule out certain diagnoses. findings consistent with a ruptured ectopic pregnancy led One of the limiting factors for implementation of PO- to a helicopter evacuation to a coastal hospital, where CUS aboard cruise ships is the need for initial and ongoing the patient received expedited definitive surgical manage- training of onboard physicians. Cruise ships move 7 days ment. Training cruise ship physicians to perform POCUS a week, 52 weeks a year, providing little time to set aside and establishing tele-ultrasound and maritime protocols for initial training or refresher courses. New physicians may streamline clinical decision-making. Future revisions frequently rotate to the ship’s medical centre, creating an of the ACEP Health Care Guidelines for Cruise Ship Medical ongoing need for initial training. Our team has found that Facilities should address the use of POCUS, and cruise lines structuring training into a port call at the home port at the should ensure that physicians working on cruises board end of one cruise and before the beginning of the next is have access to ultrasound equipment as well as to training, feasible. One team of trainers can train multiple medical tele-medical support, and ongoing quality assurance. centre teams over several days, as other ships come to the home port. Pre-recording lectures to maximize hands-on References scanning time during these trainings makes the best use 1. Cruise Lines International Association (CLIA) reveals growth in global of the small training window. and North American passenger numbers and insights. Retrieved from. https://cruising.org/news-and-research/press-room/2019/ Tele-ultrasound is the use of technology to bring ul- april/clia-reveals-growth (Accessed August 18, 2019). trasound from the bedside of a patient to the screen of 2. Cruise Industry News, “Cruise Ship Orderbook”. Retrieved from. ht- a remote expert [7]. We use a store-and-forward tele-ultra- tps://www.cruiseindustrynews.com/pdf (Accessed August 18, 201). sound system with a commercially available cloud service. 3. Health care guidelines for cruise ship medical facilities. Policy Ultrasound images are obtained by the ship’s physicians resource and education paper. January 2019. Retrieved from. ht- at the bedside and sent to our telemedicine and tele-ultra- tps://www.acep.org/globalassets/new-pdfs/preps/health-care- guidelines-for-cruise-ship-medical-facilities---prep.pdf (Accessed sound team along with clinical information and initial image December 6, 2019). interpretation. Our tele-ultrasound specialists may request 4. Ultrasound Guidelines: Emergency, Point-of-Care and Clinical further views to ensure that the patients receive the appro- Ultrasound Guidelines in Medicine. Ann Emerg Med. 2017; 69(5): priate diagnosis and targeted therapy for their condition. e27–e54, doi: 10.1016/j.annemergmed.2016.08.457, indexed in We suggest that future revisions of the ACEP Health Care Pubmed: 28442101. 5. Cruise Compete. Pregnancy policies by cruise line. Retrieved Guidelines for Cruise Ship Medical Facilities should include from. https://www.cruisecompete.com/pressrelease010810. POCUS, and cruise lines should ensure that physicians working php (Accessed August 18, 2019). on board have both access to ultrasound equipment as well 6. Moore C, Todd WM, O’Brien E, et al. Free fluid in Morison’s pouch as to training and ongoing quality assurance. on bedside ultrasound predicts need for operative intervention in suspected ectopic pregnancy. Acad Emerg Med. 2007; 14(8): CONCLUSIONS 755–758, doi: 10.1197/j.aem.2007.04.010, indexed in Pub- med: 17554008. This case report highlights an emergent medical evac- 7. Britton N, Miller MA, Safadi S, et al. Tele-Ultrasound in resource-limi- uation in a case with ruptured ectopic pregnancy that was ted settings: a systematic review. Front Public Health. 2019; 7: 244, initiated by utilising a handheld ultrasound, successfully doi: 10.3389/fpubh.2019.00244, indexed in Pubmed: 31552212.

www.intmarhealth.pl 45 Int Marit Health 2020; 71, 1: 46–55 10.5603/IMH.2020.0011 www.intmarhealth.pl ORIGINAL ARTICLE Copyright © 2020 PSMTTM ISSN 1641–9251 Is physical and psychological work stress associated with fatigue in Danish ferry ship employees?

Solveig Boeggild Dohrmann , Kimmo Herttua , Anja Leppin

Centre of Maritime Health and Society, Institute of Public Health, University of Southern Denmark (SDU Esbjerg), Esbjerg, Denmark

ABSTRACT Background: Fatigue is a recognised risk factor for safety in seafaring. While always dangerous, fatigue in ferry shipping is especially hazardous as it may jeopardise passengers’ safety. To counteract fatigue, knowledge on its determinants is important. Little, however, is known on the influence from physical and psychosocial work environment factors within ferry shipping. The aim of the study was to investigate the association between work stress in terms of physical stressors, perceived job demands and job control and different dimensions of fatigue among ferry ship employees and to test whether a potential effect of work stress was mediated by sleep satisfaction. Materials and methods: The design was cross-sectional. 193 respondents answered to a self-administered questionnaire including standardised scales, i.e. the Swedish Occupational Fatigue Inventory and the Copenhagen Psychosocial Questionnaire for job demands and control. The association of risk factors with fatigue was determined using hierarchical multiple linear regression analyses. Results: Physical work stressors were positively associated with only one of five fatigue subscales: lack of energy. Higher levels of demands were related to more lack of energy, lack of motivation, physical exertion and sleepiness, while more control was related to lesser lack of energy, lack of motivation and sleepiness. No demand-control interaction was found. Effects of demand and control were partly mediated by sleep satisfaction. Conclusions: Although limited by its cross-sectional design this study provides support for the independent relevance of demands and control for employee fatigue in ferry shipping and for a mediating role of sleep satisfaction. (Int Marit Health 2020; 71, 1: 46–55) Key words: fatigue, demand-control model, job demands, job control, psychosocial work environment, sleep satisfaction, seafaring, seafarers

INTRODUCTION and temporomandibular joint dysfunction); physical discom- Fatigue is a recognised problem in an occupational fort, pain and memory and/or cognitive degradation [3, 4], context [1–3]. It refers to ‘a state of an organism’s muscles, resulting in sickness absenteeism and work disability [5, 6]. viscera, or central nervous system, where prior physical Furthermore, fatigue is a risk factor for occupational safety, activity and/or mental processing, in the absence of suffi- particularly in the transport industry [3] including shipping cient rest, results in insufficient cellular capacity or system [3, 7–11]. Fatigue in ferry shipping is especially hazard- wide energy to maintain the original level of activity and/or ous as it may jeopardise passengers’ safety [12, 13]. processing by using normal resources’ [3]. Symptoms range Almost 89% of ferry crew members reported that tiredness from minor and quick to resolve by sufficient rest to severe had led to loss of concentration while at work, up to one and hard to alleviate or chronic [3]. third had been involved in a fatigue-related incident or In the working population the more chronic type of fa- accident and a little less than one fourth had fallen asleep tigue has been associated with impairments comparable at work more than once a month [13, 14]. These rates are to those of patients with chronic disease (e.g. fibromyalgia comparable to those in other transportation sectors (76%

Postdoc Solveig Dohrmann, PhD, Centre of Maritime Health and Society, Department of Public Health, University of Southern Denmark, Niels Bohrs Vej 9, * 6700 Esbjerg, Denmark, tel: 0045 6550 4242, e-mail: [email protected]

46 www.intmarhealth.pl Solveig Boeggild Dohrmann et al., Is work stress associated with fatigue in Danish ferry ship employees? in seafaring [15], 71% in road transportation [16], 75–90% The objective of the present article was therefore to in aviation [17]) but considerably higher than the 16–38% investigate if physical work environment stressors as well reported from the general work force [18–20]. as perceived job demands, and job control had an addi- A first step towards counteracting this problem by pre- tive effect on different dimensions of fatigue among crew ventive programmes is acquiring knowledge about factors members and terminal workers in Danish ferry shipping. determining fatigue in seafaring [7, 8]. Recent systematic Further, an interactive effect between job demands and reviews on fatigue in seafarers found most evidence to job control on the different dimensions of fatigue was be available for proximal influence factors, such as sleep tested. Finally, it was investigated whether a potential deprivation and irregular work-rest scheduling [8, 21, 22]. effect of work stress is mediated by sleep satisfaction. In contrast, the role of specific work tasks and working conditions, including the physical and psychosocial working MATERIALS AND METHODS environment has been investigated by too few studies The present study was based on a cross-sectional sur- to provide any conclusive evidence [21]. However, these vey design, using a standardised questionnaire battery for factors have been consistently linked to fatigue in onshore data collection. The checklist ‘Strengthening the Reporting working populations [18, 23–25]. of Observational Studies in Epidemiology’ was used for According to the Demand-Control model [26], which guidance of reporting [31]. has been widely used in international research on occupational stress since the 1980s, strain results from the Participants and procedure experienced level of job demands as well as the level Participants were recruited from two Danish ferry ship of control over tasks and the way they are performed companies; Company 1 operating five domestic and two in- [25–27]. The impact can occur either due to main or buffer ternationals services (all services were included in the study) effects. According to the former, high strain results separate- and Company 2 operating three international services (one ly from either high demands or low control or both, while the service was included into the study). Data was collected from latter predicts that high demands lead to strain only when April to the end of September 2015. Ferry ships were laid up perceived control is low [26]. overnight meaning that most crew members slept at home To the authors’ knowledge no study has yet applied the (though still on call during their service periods), alternatively Demand-Control model in ferry shipping and no studies have in onshore watch rooms. Therefore, preconditions, such as tested the suggested buffering effect in a seafaring context. sleeping environments and schedules (including working However, a recent study tested the effect of job demands in early mornings, evenings and late nights) were mostly similar seafarers working on board cargo ships, container ships and and both groups were considered eligible for the study and passenger lines and found high job demands to be associat- invited for participation via written information materials. ed with physical symptoms (e.g. gastrointestinal discomfort) The questionnaire was made available to 513 employees, and unhealthy behaviours (e.g. smoking) [28]. Yet another electronically on the companies’ intranet as well as in study used the main effects model in seafarers of supply a printed form; Company 1: n = 281 and Company 2; n = 232 vessels for the oil and gas industry and found high levels (179 terminal workers and 334 crew members), and 193 of demands as well as low levels of control associated with employees returned a completed questionnaire yielding more fatigue [29]. However, this specific subgroup of em- a response rate of 56% and 16%, respectively. Characteris- ployees may not be representative for seafarers in general. tics of the study population are presented in Table 1. High levels of job demand and/or low levels of job The study was approved by the Danish Data Protection control have an adverse influence on sleep quality in land- Agency [32]. According to Danish law questionnaire surveys based occupations [23]. Furthermore, the body of literature like the one used in the present study do not need approval has shown that sleep deprivation and/or poor-quality are from an ethics committee (§14) [33], and consent to par- associated with higher levels of fatigue among seafarers ticipate was given by ‘explicit enactment’, i.e. by submitting [8, 21, 22], and it supports a mediating effect from sleep the questionnaire (§3) [32, 34]. quality on other outcomes than fatigue in onshore settings (e.g. sleep fragmentation has been found to mediate the Measurement relationship between social climate and psycho-somatic Outcome complaints among full time employees in finance, health Fatigue was assessed using the second version of the care and management [30]). Despite this, to date, a poten- Swedish Occupational Fatigue Inventory (SOFI) [1]. The tial mediating effect from sleep-related factors on fatigue English version was translated into Danish using the trans- has yet to be tested in an onshore- as well as in a seafaring lation/back-translation technique [35]. SOFI includes 20 context. symptoms of fatigue to be rated on response scales from

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Table 1. Characteristics of the study population and the working environment

Number Per cent Mean SD Age 172 47. 6 12.4 Gender (female) 19 11 School education ≥ 7th grade — technical school 90 57 Gymnasium education 68 43 Professional education Vocational training 77 45 University college and university 94 55 Professional group Officers 102 53 Non-officers 91 47 Living with a partner (yes) 135 78 Children under 6 years old (yes) 25 15 Ferry ship company Company 1 156 81 Company 2 37 19 Workplace Terminal 34 18 Ferry ship 158 82 Number of workdays per week 179 3.85 0.90 Typical time of work Day and evening 96 52 Day, evening and night 89 48 Sleeping at the workplace/on board (yes) 72 45 Physical activity 0–4 hours per week, low intensity 53 31 ≥ 2 hours per week, high intensity 119 69 Smoking (yes) 43 25 Sleep satisfaction (1 [low] – 10 [very high]) 167 6.42 2.34 Disturbance by the physical work environment 189 2.07 0.71 (1 [low disturbance] — 5 [high disturbance]) Job demands (0 [low] – 25-50-75-100 [high]) 184 48.86 14.18 Job control (0 [low] – 25-50-75-100 [high]) 185 48.78 18.10 SOFI — Lack of energy (0 [very low] – 6 [very high]) 166 2.02 1.55 SOFI — Physical exertion (0 [very low] – 6 [very high]) 166 1.21 1.31 SOFI — Physical discomfort (0 [very low] – 6 [very high]) 166 1.48 1.43 SOFI — Lack of motivation (0 [very low] – 6 [very high]) 166 1.56 1.45 SOFI — Sleepiness (0 [very low] – 6 [very high]) 166 1.79 1.40 SOFI — Swedish Occupational Fatigue Inventory; SD — standard deviation

0 = ‘not at all’ to 6 = ‘to a very high degree’ with regard to sub-dimensions: 1) lack of energy (LE), 2) physical exertion how respondents felt when they had been most tired at (PE), 3) physical discomfort (PD), 4) lack of motivation (LM), work during the last 4 weeks. The instrument involves five and 5) sleepiness (S) with four items each [1]. A sum score

48 www.intmarhealth.pl Solveig Boeggild Dohrmann et al., Is work stress associated with fatigue in Danish ferry ship employees? was calculated for each of the five subscales [1]. Cronbach’s one fatigue dimension on the bivariate level (p < 0.05), were alphas for the subscales ranged from 0.86 to 0.93. included as potential confounding factors in the multivariable analyses. The only exception to this was ‘vocational Exposures education’. Since this variable was highly correlated with Demand and control were assessed by four subscales ‘professional group’, only the latter factor was included in of the Copenhagen Psychosocial Questionnaire (COPSOQ) — the subsequent analyses. a validated Danish counterpart to the Job Content Ques- Prior to multivariable analyses, potential violations of tionnaire [36] (‘quantitative demands’ [4 items], ‘work pace’ assumptions in terms of linearity, multivariate normality, [3 items], ‘influence at work’ [4 items], and ‘opportunities homoscedasticity and multicollinearity were checked for. for professional development’ [4 items]). All 15 items were Between 0 and 7 multivariate outliers were detected (stan- to be rated either on a 5-point scale indicating frequency dard residual > 3 standard deviations), and the respective (‘always’ to ‘almost never/never’) or agreement (‘to a very cases were removed from the final models, leaving the large extent’ to ‘to a very small extent’). ‘Quantitative de- sample size ranging from n = 193 (LE, LM, S) over n = 191 mands’ and ‘work pace’ were then added up to a total ‘job (PD) to n = 186 (PE). demands’-scale while ‘influence at work’ and ‘opportunity for Five models were designed for the prediction of the five professional development’ were summed up to a summary fatigue dimensions. On step one, age, gender and those ‘job control’-scale [36]. Cronbach’s alphas ranged from 0.79 individual or job characteristics which had been associated to 0.82. To test the interaction between job demands and with one of the fatigue dimensions on the bivariate level job control the two variables were first centred and then (p < 0. 05) were adjusted for. Environmental stressors, job multiplied. demands, job control and the demand-control interaction term were entered on step 2 (Table 3, Model 1). Covariates To additionally test for a mediating effect of sleep satis- Socio-demographic characteristics, such as age, gen- faction, another hierarchical model with the same covariates der, country of birth, school education (technical college/ was run for predicting sleep satisfaction (Table 3, Model 1), /gymnasium education), professional education (vocational after which sleep satisfaction was entered as a final variable training/university college and university) and living with into all five regression equations for the fatigue sub-dimen- a partner (no/yes) were considered as standard covariates. sions (Table 3, Model 2). Age, sleep satisfaction, physical Also, professional group (officers/non-officers), ferry ship environment stress, job demands, and job control were company (company 1/2), workplace (ship/terminal), number entered as continuous, all others as binary variables. All of workdays per week, night work (no night work/night work analyses were conducted with SPSS Statistics 24. [indicating shift work]), sleeping at the workplace (yes/no), children under six living at home (no/yes), physical activity RESULTS (0–4 hours per week, low intensity/≥ 2 hours per week, high Ninety-eight per cent of the study population were Dan- intensity) and smoking (no/yes) were tested [11, 22, 23, 37]. ish citizens, 89% of whom were male, and mean age was Satisfaction with sleep was assessed via a 10-point rating 47.6 (range from 19 to 70) (Table 1). Approximately 50% scale (from ‘completely satisfied’ to ‘not satisfied at all’). were officers, 80% were working on board of ferries, and for Finally, five single-item questions were used for measuring 50% typical work time involved night shifts. Disturbance by physical work environment stressors (noise, vessel move- the physical working environment was low to moderate on ments, vibrations, heat, cold) based on 5-point frequency average while mean scores for demand and control were rating scales (‘almost all the time’ to ‘almost never’). The in the medium range, and for fatigue at the lower end of five measures were combined into an overall index, i.e. the scale. a sum-up score of all five items [11, 21, 22, 37]. As data came from individual employees nested within different organisational units (terminals and ships), multi- Data analysis level analyses might have been required. Mixed effect null When summing up scores for the SOFI- and COPSOQ-sub- models showed that a maximum of 4% of the variance in scales missing values were replaced by individual subscale fatigue could be attributed to between cluster differences means in accordance with the instrument’s guidelines (intra-class correlations: LE = 0.016, PE = 0.00, PD = 0.021, [1, 36]. Point-biserial and Pearson correlations were used LM = 0.04, S = 0.02). Due to these low coefficients, stan- to determine bivariate associations between fatigue scores dard multiple hierarchical linear regression was used [38]. and potentially associated variables, and the results are In the initial model, physical stressors were positively presented in Table 2. Age, gender and those individual or associated with lack of energy (b = 0.23), physical exertion job characteristics which had been associated with at least (b = 0.23), physical discomfort (b = 0.25) and sleepiness

www.intmarhealth.pl 49 Int Marit Health 2020; 71, 1: 46–55

Table 2. Bivariate correlations between personal characteristics, worksite characteristics, work stressors and different dimensions of fatigue

SOFI — Lack SOFI — Physical SOFI — Physical SOFI — Lack SOFI — of energy exertion discomfort of motivation Sleepiness Age –0.02 –0.05 –0.08 –0.13 –0.13 Gender1 0.10 0.02 0.21** 0.06 0.14 School education2 0.05 –0.04 0.01 0.03 0.05 Professional education3 –0.11 –0.06 –0.20* –0.12 –0.16* Professional group4 0.14 0.06 0.21** 0.13 0.18* Living with a partner5 0.04 0.10 0.11 0.01 0.07 Children under 6 years6 –0.12 –0.06 –0.10 –0.07 –0.07 Ferry ship company7 0.09 0.02 0.13 0.04 0.10 Workplace8 –0.13 –0.09 –0.16* –0.14 –0.20* Number of workdays per week –0.08 –0.04 0.07 –0.13 –0.06 Typical work time9 0.20* 0.16* 0.26** 0.17* 0.19* Sleeping at the workplace/on board10 –0.12 –0.08 –0.13 –0.13 –0.15 Physical activity11 –0.10 0.01 –0.04 –0.04 –0.07 Smoking12 0.05 0.02 0.07 0.02 –0.01 Sleep satisfaction –0.50** –0.38** –0.42** –0.50** –0.56** Disturbance from the physical work environment 0.39** 0.26** 0.33** 0.26** 0.30** Job demands 0.40*** 0.30*** 0.27*** 0,34*** 0.36*** Job control –0.25** –0.20* –0.17* –0.30** –0.27** SOFI — Lack of energy 1 0.66*** 0.70*** 0.80*** 0.82*** SOFI — Physical exertion 0.66*** 1 0.67*** 0.74*** 0.72*** SOFI — Physical discomfort 0.70*** 0.67*** 1 0.60*** 0.67*** SOFI — Lack of motivation 0.80*** 0.74*** 0.60*** 1 0.84*** SOFI — Sleepiness 0.82*** 0.72*** 0.67*** 0.84*** 1 *Significant value: p < 0.05; **Significant value: p < 0.01; ***Significant value: p < 0.001; SOFI — Swedish Occupational Fatigue Inventory 1Female = 2; 2Primary school = 1, secondary school = 2; 3Vocational training = 1, university college/university = 2; 4Officers = 1, non-officers = 2; 5Yes = 2; 6Yes = 2; 7Company 1 = 1, Company 2 = 2; 8Terminal = 1, ferry ship = 2; 9Day and evening = 1, day, evening and night = 2; 10Yes = 2; 110–4 hours per week/low intensity = 1, ≥ 2 hours per week/high intensity = 2; 12Yes = 2

(b = 0.17). Job demands were positively associated with Adding sleep satisfaction to the models predicting fa- lack of energy, physical exertion, lack of motivation and tigue showed a significant association of this factor with sleepiness after controlling for potential confounders all five aspects of fatigue, indicating that higher subjective (LE, b = 0.33; PE, b = 0.21; LM, b = 0.32; S, b = 0.31; Ta- sleep quality was associated with less experience of fatigue ble 3, Model 1) while negative associations with the same (Table 3, Model 2). In these final models, physical-envi- subscales were found for job control (LE, b = –0.26; PE, ronment work stressors were only associated with lack of b = –0.24; LM, b = –0.36; S, b = –0.28). In contrast, for energy (b = 0.16), physical exertion (b = 0.18) and physical none of the outcomes did the findings suggest an interaction discomfort (b = 0.20). Higher levels of perceived demands between job demands and job control. were still significantly associated with more lack of energy Testing additionally for associations between job-re- (b = 0.25), lack of motivation (b = 0.25), and sleepiness lated stress and sleep satisfaction showed that perceived (b = 0.23). Similarly, more job control was related to lesser stress from the physical environment and job demands lack of energy (b = –0.19), physical exertion (b = –0.18), lack were negatively (b = –0.19, b = –0.22) and job control pos- of motivation (b = –0.28) and sleepiness (b = –0.19). Again, itively associated with perceived sleep quality (b = 0.22). there was no indication of a demand-control interaction. No indication for a demand-control interaction was found Comparing prior findings for the association between (Table 3, Model 1). work stress factors and fatigue without adjustment for sleep

50 www.intmarhealth.pl Table 3. Multivariable associations between physical and psychosocial work stressors, sleep satisfaction and different dimensions of fatigue

SOFI — Lack of energy SOFI — Physical exertion SOFI — Physical SOFI — Lack of motivation SOFI — Sleepiness Sleep satisfaction

(n = 156) (n = 149) discomfort (n = 154) (n = 154) (n = 154) (n = 156) Solveig BoeggildDohrmannetal.,IsworkstressassociatedwithfatigueinDanishferryshipemployees?

Model 1 b R2 R2 change b R2 R2 change b R2 R2 change b R2 R2 change b R2 R2 change b R2 R2 change

Age 0.04 –0.01 0.02 0.00 –0.02 –0.05

Gender a 0.01 –0.07 0.15 –0.01 0.04 –0.18*

Workplace b –0.07 –0.07 –0.01 –0.04 –0.07 –0.16

Professional groupc –0.01 –0.13 0.08 –0.04 0.02 –0.09

Typical time of workd 0.04 0.07 0.10 0.04 0.18* 0.13** 0.07 0.07 0.08 0.10** 0.02 0.08*

Physical working 0.23** 0.23** 0.25** 0.15 0.17* –0.19* environment www.intmarhealth.pl Job demands 0.33*** 0.21* 0.14 0.32*** 0.31*** –0.22*

Job control –0.26** –0.24** –0.10 –0.36*** –0.28*** 0.22**

Demand*control 0.06 0.32*** 0.25*** 0.10 0.25*** 0.19*** 0.09 0.29** 0.12** 0.10 0.34*** 0.26*** 0.06 0.31*** 0.22*** –0.06 0.22*** 0.15***

Model 2 b R2 R2 change b R2 R2 change b R2 R2 change b R2 R2 change b R2 R2 change b R2 R2 change

Age 0.02 –0.03 –0.01 –0.03 –0.05

Gender –0.06 –0.12 0.11 –0.06 –0.04

Workplace –0.13 –0.12 –0.05 –0.10 –0.15*

Professional group –0.04 –0.15 0.06 –0.07 –0.01

Typical time of work 0.05 0.07 0.10 0.04 0.18* 0.13** 0.08 0.07 0.08 0.10**

Disturbance by physical 0.16* 0.18* 0.20* 0.08 0.08 working environment

Job demands 0.25** 0.16 0.10 0.25** 0.23**

Job control –0.19** –0.18* –0.05 –0.28*** –0.19**

Demand*control 0.04 0.32*** 0.25*** 0.09 0.25*** 0.19*** 0.07 0.29** 0.12** 0.08 0.34*** 0.26*** 0.04 0.31*** 0.22***

Sleep satisfaction –0.35*** 0.42*** 0.10*** –0.25** 0.30** 0.05** –0.24** 0.33** 0.04*** –0.34*** 0.43*** 0.09*** –0.42*** 0.45*** 0.13*** Model 1: Prediction models without sleep satisfaction. Model 2: Prediction models including sleep satisfaction. b — standardized regressions coefficient;2 — R square;R R2 change — R square change. *Significant value: p < 0.05; **Significant value: p < 0.01; ***Significant value: p < 0.001;aFemale = 2.b Terminal = 1, ferry ship = 2.cOfficers = 1, non-officers = 2.dDay and evening = 1, Day, evening and night = 2; SOFI — Swedish Occupational Fatigue Inventory 51 Int Marit Health 2020; 71, 1: 46–55 satisfaction (Table 3, Model 1) and subsequent findings af- their later forties, half of whom were officers and for half of ter adjustment (Table 3, Model 2) showed that in particular whose typical worktime involved night shifts) are in line with the significant associations for demand and control with the those of the general population of crew members working different aspects of fatigue remained but were reduced in in Danish ferry shipping [41], and 2) that comparison of size. Adding sleep satisfaction to the models significantly study participants and the total of employees did not show increased explained variance in all fatigue sub-dimensions any significant difference in terms of age, gender, rank or (Table 3, Models 1 and 2) by 4% (PD) to 13% (S) with overall working at a terminal versus on board ferry ships. explained variance ranging between 30% (PE) and 45% (S). The role of job demands and job control DISCUSSION Findings from the present study are consistent with the This study aimed to test additive and interactive effects assumption of an association between physical and psycho- of work stress levels on different dimensions of fatigue and social work stressors and fatigue in Danish ferry shipping revealed supportive evidence only for additive effects. employees. Perceived job demands, and job control were Effects tended to be stronger for psychological than for generally more important than disturbance from the physical physical aspects of fatigue and adding sleep satisfaction working environment, which may reflect a general tendency improved predictive power while reducing the effect sizes in seafaring towards a reduction of strenuous manual labour for job demands and control, suggesting that parts of performed primarily outdoors in inclement conditions. In the effects of perceived job demands and control are the same vein, it is notable that the potential impact of job mediated via sleep quality. demands, and control was primarily expressed in terms of lack of energy, lack of motivation and sleepiness rather Limitations of the study than physical exertion or discomfort [1]. This too indicates Given the cross-sectional design of the study the ob- that ferry shipping nowadays might be more mentally than served associations are not interpretable as cause-effect physically fatiguing [42], given a context characterised by associations. Thus, to which extent perceived demands and time pressure and late and/or shifting working hours. control increase fatigue or higher levels of fatigue contrib- In accordance with the strain hypothesis of the de- ute to perception of higher demands and lower experience mand-control model [26] results from the present study of control or — most likely — there is a genuine reciprocal clearly support an additive effect of job demands and job influence, cannot be determined. Causal ambiguity is also control on fatigue; especially the psychological fatigue di- created by using a self-report questionnaire, and self-report mensions and sleepiness. No support was found for the buf- measures are known to be prone to biases such as recall fer hypothesis since there was no indication of an interaction bias, social desirability bias and negative affectivity [39]. effect. This agrees with findings from many other studies in Thus, for instance, respondents with higher fatigue prob- the occupational field as documented by a series of reviews lems might be more likely to recall and report high demands [25, 27, 43]. However, it remains unclear to which extent and low control and vice versa. Moreover, it cannot be ex- this prevalent lack of buffering effects may be due to concluded that respondents in general underreported fatigue ceptual limitations. It has been suggested that there must since high fatigue levels at work are considered problematic, be a close match between the type of demands and the even though all participants were assured confidentiality of available coping resource for buffering to occur [44], while data and were able to submit their responses without per- broader types of measures such as the ones used in the sonal identification. A further limiting factor is the response present as well as many other studies might have problems rate since in particular the low response of employees detecting such effects [25, 27]. Interpreting present results from Company 2 implies the possibility of selection effects in this light, it is suggested that a general sense of control in terms of non-response/selective response and thereby might not be an adequate resource to buffer the effect from potentially biased results [40]. Despite assurances of con- job demands on fatigue in a highly regulated workplace fidentiality it cannot be excluded that some of those with where all tasks are subjected to strict time schedules. In higher fatigue or more work stress were more reluctant to such circumstance’s decision latitude, while still important, participate in the survey while reverse effects, i.e. employees as reflected in the main effect found, may have less impact with higher dissatisfaction being more motivated to partic- on the level of task demands, which might make buffer- ipate in a work-place survey have also been known. As for ing more difficult. As outlined in the introduction section, external validity the low participation rate in Company 2 and findings from other studies, though still few, suggest that in general of those working the terminals are limiting the psychosocial factors are linked to fatigue in ferry shipping generalisability of the study findings. Still, it should be noted as well as in other sectors of the seafaring industry [8, 21, that 1) other characteristics of the study sample (males in 22, 28, 29]. As occupations and activities undertaken in

52 www.intmarhealth.pl Solveig Boeggild Dohrmann et al., Is work stress associated with fatigue in Danish ferry ship employees? this industry are various, heterogeneity in psychosocial or actual coping behaviour when it comes to dealing and/or fatigue profile across sectors is possible [3, 45]. with stressors, such as job demands [49]. Recently two This is further supported by considering that psychosocial studies have investigated resilience and perceived stress factors, like job demands and job control, originate from among merchant seafarers, and this concept was found highly specific social structures and contexts [46, 47], as to be cross-sectionally associated with and identified as well as fatigue measurement may hinge upon the interpre- a predictor of perceived stress (two point of measurement; tation of words presented in measurement tools and/or 10 months follow up) [50, 51]. Therefore, untangling the depend on the interpretation of fatigue-related signs [3]. complex nature of these pathways seems of great impor- However, studies that investigate heterogeneities in profiles tance. It requires future studies using a greater variety and associations between factors in a seafaring context are of outcomes and longitudinal designs. However, such seemingly still lacking, and therefore it remains uncertain studies are not common in seafaring yet and they are to what extent ferry crew members show different associa- also difficult to implement in this research area [21, 22]. tions as compared to other sea- or land-based occupational groups. Therefore, it is important that future knowledge on Implications psychosocial working conditions and fatigue in seafaring The relative low fatigue levels found in this study may is derived from studies that allow for 1) an investigation suggest that there is a limited need for fatigue-mitigation of a more complex and specific nature of occupation-spe- in the Danish ferry shipping industry. However, variations cific work factors and their relationship with fatigue, and in fatigue levels may suggest that some sub-groups still 2) a comparison between type of ships and/or groups of require interventions, for instance those working in the ter- seafarers [11, 48]. minal and/or non-officers. Further, fatigue has been found to rise over time of duty, also in ferry shipping [9, 42, 48], The role of sleep satisfaction and even fatigue levels that are not critically high from As expected, lower job demands and higher job control a perspective of individual health and well-being can were associated with higher subjective sleep satisfaction, endanger the safety of the crew and passengers [3, 7]. while sleep satisfaction again attenuated the relation be- In addition, the present study mainly focused on services tween job demands, job control and fatigue suggesting where ferry ships were laid up overnight. Fatigue-profiles that a potential effect of these factors on fatigue is partly may differ between non- and overnight services, sug- mediated by sleep quality. Associations between sleep gesting future studies to (also) include ferry ships with deprivation/poor sleep quality and higher levels of fa- complete nightshift to investigate this in greater details. tigue have been recognised in other types of seafaring than ferry shipping [11, 21] and in other occupational Job demands and job control branches [3, 24]. In a prospective study examining the Results from this study indicate that demand-reducing causal direction of longitudinal relations between job and control-supporting initiatives should be included into demands, job control, sleep quality and fatigue among such strategies. Based on research in onshore occupations, blue- and white-collar workers, higher demands over ferry shipping companies are encouraged to focus future time were related to increased sleep complaints, while fatigue-prevention initiatives around staffing adequacy (e.g. higher levels of job control led to fewer complaints [23]. adding manpower during peak times) [52–54], task vari- Moreover, workers exposed to an increasing amount ety (e.g. rotating schemes) [52–54], flexibility in working of high-strain work over time reported more sleep com- arrangements (e.g. participation in duty roster planning) plaints, which also increased over time, while this was [55] and participation in workplace decision making (e.g. not the case for their counterparts in stable low strain or in planning of demand-reducing and control-enforcing ini- active jobs [23]. It is certainly plausible that a stressful tiatives) [52–54], which have been found to have a posive psychosocial work environment negatively affects sleep, impact on perceived job demands and job control. which again results in feelings of fatigue. However, fa- tigued employees are also likely to perceive work tasks Sleep satisfaction as more demanding or to experience less control, thus Besides job demands and job control it seems that there reinforcing prior levels of fatigue. is a need for also including sleep-related initiatives into It is interesting to note, though, that while sleep sat- fatigue-preventive strategies. In fact, sleep is an important isfaction was a mediator, it did not account for the whole factor to human health, and lack of sleep and poor sleep association between job strain and fatigue, suggesting quality have been associated with risk of stress and strain further pathways such as demotivation or burnout pro- among workers, including seafarers [8, 11, 21, 22]. Further, cesses and/or differences in individual coping resources evidence has shown that the psychosocial work environ-

www.intmarhealth.pl 53 Int Marit Health 2020; 71, 1: 46–55 ment is relevant for sleep. For instance, in accordance with 7. Allen P, Wadsworth E, Smith A. Seafarers’ fatigue: a review of the the results of the present study high levels of job demands recent literature. Int Marit Health. 2008; 59(1-4): 81–92, indexed in Pubmed: 19227741. and lower levels of job control have been found to have 8. Jepsen J, Zhao Z, Pekcan C, et al. Risk factors for fatigue in an adverse influence on sleep quality [23]. While there shipping, the consequences for seafarers’ health and options for is general evidence in favour of psychosocial and health preventive intervention. Maritime Psychology. 2017: 127–150, effects of workplace interventions [52–54], there is still doi: 10.1007/978-3-319-45430-6_6. a need for more research testing the impact of changes in 9. Barnett M, Pekcan C, Kecklund G, et al. Project MARTHA. The Final the psychosocial work environment on sleep quality. Given Report. 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www.intmarhealth.pl 55 Int Marit Health 2020; 71, 1: 56–61 10.5603/IMH.2020.0012 www.intmarhealth.pl ORIGINAL ARTICLE Copyright © 2020 PSMTTM ISSN 1641–9251 Safety behaviour and healthy diving: a qualitative study in the traditional diverse fishermen

Kusnanto Kusnanto1 , La Rakhmat Wabula2 , Bambang Purwanto3 , Hidayat Arifin2 , Yulia Kurniawati2

1Department of Fundamental, Medical-Surgical and Critical Nursing, Faculty of Nursing, Universitas Airlangga, Kampus C, Mulyorejo, Surabaya, Indonesia 2Master of Nursing Study Programme, Faculty of Nursing, Universitas Airlangga, Kampus C, Mulyorejo, Surabaya, Indonesia 3Department of Medical Science, Faculty of Medicine, Universitas Airlangga, Kampus A, Surabaya, Indonesia

Abstract Background: Traditional divers from the Maluku Province of Indonesia have not received formal education and training related to standard diving tools. They only become accomplished at diving generation by generation. The use of non-standard diving tools increases the risk of injury and illness. This study aimed to get an overview of the health and safety behaviours of traditional divers. Materials and methods: The study was qualitative, involving 15 traditional divers who used compressors for at least 1 year and who’d had decompression sickness and barotrauma as a result of diving. The data was obtained through in-depth interviews, analysed through the Colaizzi method. Results: The participants’ diving health and safety behaviour is triggered by the perception of the risk of diving. This is supported by the reinforcing social and environmental factors leading to the form of health and safety behaviour when diving. These behaviours include diving without planning, using a compressor, and making “sesajen” (kind of food, leaves, and water that are believed to be a form of surrender to the creator) which is an offering or present to the gods or ancestors. This behaviour causes complaints such as trauma and an increased economic burden. Some participants consider complaints as a threat and plan to stop diving. The participants made a plan before dive and declared that they would change their behaviour to ensure safety. Conclusions: Health and safety behaviour related to diving must be socialised and facilitated. The establishment of a divers’ community that cares about health and safety behaviour needs to become important as a support system. (Int Marit Health 2020; 71, 1: 56–61) Key words: health and safety behaviours, diving incident, traditional divers

INTRODUCTION the existing facilities and infrastructure cause the using Traditional divers are spread across the territory of Indone- of compressors to be an alternative to Self-Contained Un- sia, especially in the Coastal and Archipelago areas [1]. The div- derwater Breathing Apparatus (SCUBA) diving equipment. ing expertise of traditional divers is obtained from generation Data from 2014 to 2017 on the prevalence of barotrauma, to generation. Traditional divers have not received any formal paralysis, and the bites of marine animals increased by diving education and training. The health and safety behaviour 25% due to the non-compliance with the health and safety for diving is not standard. The risk of injury and illness due to diving standards [2]. non-standard behaviour when diving is increased [2]. Diving is a high-risk job. The increasing of work pro- Traditional divers total 1694 (29%) of fishermen who ductivity refers to excellent, safe diving standards and the can dive to a 20 m depth or more. The limitations within knowledge of the traditional divers about the risk of hazards

Dr. Kusnanto Kusnanto, S. Kp., M. Kes., Department of Fundamental, Medical-Surgical and Critical Nursing, Faculty of Nursing, Universitas Airlangga, Kampus C, Mulyorejo, * Surabaya, Indonesia, Postal address: 60112, tel: (031) 5913257, 5913754, fax: (031) 5913257, e-mail: [email protected]

56 www.intmarhealth.pl Kusnanto Kusnanto et al., Health and safety behaviour of traditional divers: a qualitative study in high-pressure environments [3]. Non-adherence to safety was analysed using the Colaizzi method consisting of seven has fatal consequences such as hearing loss [4, 5]. The stages, namely: 1) describing the phenomena; 2) mark- prevalence of ear barotrauma, which includes pain (47.9%), ing keywords; 3) formulating meaning; 4) determining the transient deafness with tinnitus (27.5%) and vertigo (9.9%), theme groups; 5) integrating the theme and sub-theme are some of the side-effects of non-compliance with the descriptions; 6) formulating descriptions for a complete standard diving rules [3]. set of themes; 7) the validation of the research results This study aimed to get an overview of the health and with the participants. safety behaviour of traditional divers. The results of this study are expected to provide factual information about the Ethical considerations health and safety behaviour of traditional divers. Health care All of the participants gave their informed consent to providers will thus be able to provide interventions according be involved in the study. This study has been registered to the participant’s needs. and it passed the research ethics committee of the Health Research Ethics Commission of the Faculty of Nursing, Air- MATERIALS AND METHODS langga University with letter number: 1244-KEPK published st Research design on 31 December 2018. The study used a qualitative design through semi-structured in-depth interviews. RESULTS Participants’ characteristics Sample In-depth interviews were carried out with the 15 The participants of this study were the traditional divers participants for 30–40 min. All of the participants were and fishermen residing in Ambon City, West Seram District men aged 22–62 years old. The length of their use of and Buru Regency Maluku Province, East Indonesia. The compressor varied between 2 and 40 years. The histo- inclusion criteria were as follows: 1) participants with de- ry of paralysis experienced also varied between 1 and compression sickness and barotraumas caused by diving; 6 times. The characteristics of the participants have been 2) a history of diving using a compressor; 3) a history of work- summarised in Table 1. ing as a traditional diver for at least 1 year; 4) 25–64-year- -old ; 5) communicate verbally well. Based on the recruit- Themes ment results, 15 participants met the inclusion criteria. A total of 5 themes emerged from the results of the in-depth interviews. The themes include: 1) the perception Instrument of the diving risk; 2) the supporting factors of diving; 3) the The researcher was an instrument of the qualitative form of work-based health and safety behaviour; 4) the study. This means that from the beginning through to the impact of occupational health and safety behaviour; 5) the end of the study, the researcher was actively involved in the behaviour after being affected. The themes and sub-themes research. The data collection was assisted by a recording have been summarised in Table 2. device and an in-depth interview guideline list. The interview questions included: 1) the perception of the diving risks; Perception of diving risk 2) the supporting factors for the diving health and safety This theme explains the initial views on the risks of behaviour; 3) the form of health and safety behaviour when diving. The participants considered diving at a depth of diving; 4) any perceived impact due to the diving action; more than 100 m to be familiar to a person known to them, 5) behaviour after-effects. Field notes are also used to record so the participant did the same. They think there are no situations and events including the non-verbal expressions health and safety risks (Table 3, quotes 1–3). Some of the that were shown by the participants during the interviews. participants think that their work as a diver has risks to do with health and safety, but the risk can be eliminated Time and place by prayers and “sesajen” (food, leaves, and water that is The study was conducted from 15th January to believed to be a form of surrender to the creator) which is 15th February 2019. The location of the interview was at the an offering or present to the gods or ancestors (Table 3, participant’s homes. The interview was carried out in three quotes 4–5). phases: preparation, implementation, and termination. Supporting factors of the diving health and Data analyses safety behaviour The results of the data collection were examined im- This theme focuses on the participants’ and their fami- mediately after the interview process. The interview data ly’s perceptions of the things that are known, experienced,

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Table 1. Characteristics of respondents

Code Gender Age [year] Compressor usage [year] Paralysis history [time] P01 Male 48 8 2 P02 Male 44 21 3 P03 Male 80 40 6 P04 Male 43 10 2 P05 Male 46 29 3 P06 Male 46 15 5 P07 Male 50 2 1 P08 Male 47 2 1 P09 Male 47 23 2 P10 Male 35 6 2 P11 Male 32 2 1 P12 Male 22 3 1 P13 Male 38 5 1 P14 Male 29 4 1 P15 Male 33 2 1

Table 2. Summary of themes and sub-themes Forms of diving health and safety behaviour This theme explains how the forms of health and safety Themes Sub-themes behaviour when diving have been carried out by the partici- Perception of diving 1. No risk risk 2. Risk, but can minimize by “sesajen” pants and how they have become part of life as a traditional diver. The participants dive without planning because their Supporting factors of 1. Improper knowledge diving health and 2. Material support abilities and diving habits get transmitted from generation safety behaviour 3. Generation-to-generation habit to generation (Table 3, quote 10). All of the participants use Form of diving health 1. Without planning compressors as diving equipment because it is the only thing and safety behaviour 2. Compressor usage that is available and economically affordable for them (Table 3, 3. “Sesajen” or prayer quotes 11–12). Some of the participants prepare “sesajen” Impact of occupational 1. Trauma before diving. The “sesajen” is considered to be an acceptance health and safety 2. Economic burden and tribute during diving and fishing (Table 3, quotes 13–14). behaviour 3. Perceived health complaint Behaviour after being 1. Stop diving Impact of occupational health and safety behaviour affected 2. Behavioural change This theme focuses on the participants’ experience of the perceived impact on their health and safety behaviour when diving. All of the participants had experienced a history of paralysis (Table 3, quote 15). The effects of diving using and considered to strengthen the health and safety be- a compressor were joint pain, hearing loss, and paralysis (Table 3, haviour when diving. Knowledge about the risks of diving is quote 16–17). The participants experienced disability and trau- improper. Generation-to-generation behaviour when diving ma after losing their ability to walk (Table 3, quote 18). The par- causes the participant to maintain inadequate health and ticipants felt the economic burden due to disability. They had safety behaviour when diving (Table 3, quotes 6–7). Mate- also increased their spending on medical treatment (Table 3, rial support from the couples includes preparing “sesajen” quotes 19–20). The participants had previously taken medi- before diving. This becomes a reinforcing factor for the cation but stopped for financial reasons (Table 3, quote 21). participant to maintain their health and safety behaviour when diving (Table 3, quote 8). The strengthening factors Behaviour after being affected for the participants to maintain health and safety behaviour This theme illustrates how the participants decide on when diving include the familial generation-to-generation their behaviour after interpreting the impact of their health habits (Table 3, quote 9). and safety behaviour on diving. The participants feel trauma

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Table 3. Summary of quotes

1. “...I’m used to it and it’s my routine. No, it’s not dangerous... “ (P01) 2. “...the diving was a generation-to-generation habit and procedure...” (P05) 3. “...there is no risk. My parents were a diver. Not gradually in-depth, but directly 100 metres, and usually dive 10–12 hours without any rest...” (P12) 4. “...it’s risky. But before leaving, we prayed first and gave “sesajen”... “ (P09) 5. “...offer “sesajen” done by my wife before leaving for fishing” (P15) 6. “...still been a diver with a compressor for many years because my parent and grandparent used to be like that, so it seems safe...” (P03) 7. “...using a compressor is enough, “sesajen” have been helped to survive...” (P14) 8. “...the wife prepared “sesajen” before diving as a prayer to be saved...” (P13) 9. “...I don’t know. Just follow along, grandfather, parents, older adults too. It’s been descending...” (P08) 10. “... If I want to find fish, go to the sea and dive. Diving planning procedures do not exist. Apart from that, I think there is no...” (P07) 11. “...Use the compressor first. Parents also use compressors...” (P09) 12. “...use compressors, people here also use compressors...” (P07) 13. “...Preparation before diving only food and “sesajen”. My wife was prepared...” (P08) 14. “...before leaving, my wife prepares “sesajen” for the prayers and offerings of sea dwellers...” (P01) 15. “...I’ve been paralyzed. Almost all fishermen who dive here have been paralyzed...” (P05) 16. “...most often it’s ear aches and pains in my leg joints ...” (P11) 17. “...ear ache, leg pain, the worst experienced by fishermen divers here is being paralyzed...” (P14) 18. “...Many times paralyzed. Trauma, afraid that if I dive again, I will be paralyzed again...” (P06) 19. “...After this paralysis adds to the economic burden. Add expenses for the treatment...” (P01) 20. “...the need for treatment and daily necessities is more expensive, more and more...” (P13) 21. “...previously had been treated but stopped, there was no money anymore...” (P13) 22. “...Trauma, do not want to dive again. I’ve had ear scars, joint pain, until paralysis. Trauma...” (P06) 23. “...I think I still want to continue. Yes what should I do, the only work that can be done is that if my wife permits me...” (P13) 24. “...Still, want to dive again. Yes actually afraid if it hurts again. Yes, it will do the right planning before diving...” (P04)

and they won’t dive again after the paralysis (Table 3, quote knowledge and behaviours. Providing periodic education 22). Some of the participants still want to dive because of about the importance of health and safety behaviours also their economic demands (Table 3, quote 23). Participants plays an important role [10]. who plan to keep on diving again will draw up a diving plan Their wife’s support in terms of “sesajen” preparation is (Table 3, quote 24). also a reinforcing factor. Wife provides food, drinks, advice, and prayers. Most wives tend to be passive and obedient DISCUSSION related to earning money in family [11]. This encourages the need for social support outside of the family which Perception of the diving risk objectively pays attention to work-based health and safety Participants assume that diving does not pose a risk behaviours. to their health. This was because diving has been done Diving is the job of the participants and it is passed on generation to generation in the family [6]. Some of the from generation to generation. The participants dive ac- other participants consider “sesajen” to reduce the risk cording to the experience of their parents or the settlement of diving. “Sesajen” is believed to be a form of surrender residents around them [6]. The ability and diving procedure to the creator. “Sesajen” is considered to be a means of is learnt from the generation before and the absence of earning God’s protection [7]. Diving is targeted as a danger skill upgrading has become a reinforcing factor of the par- as a result of the changes in pressure, water temperature ticipants’ health and safety preparation behaviour so far. and to other underwater life [8]. Forms of diving health Supporting factors of diving health and and safety behaviour safety behaviour The participants dive without planning the related health The participants’ perceptions of diving were not risky and and safety behaviour when diving. What they prepared was “sesajen” is seen of as a means of requesting protection related to most of their logistical needs during the dive. This from God. This inaccuracy of knowledge is contradictory to is associated with the traditional divers generally. They only the results of the research that found that the older workers dive according to the generation to generation procedure or have better health and safety behaviour [9]. It turns out that they follow others. They were not equipped with an adequate age is not the primary determinant of work health and safety knowledge of health and safety behaviour on diving [3].

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The participants only use a compressor as their diving diving, the more nitrogen is absorbed by the body. This can equipment. This is consistent with other studies stating lead to undesirable things such as weakness while in the that in general, traditional divers use a compressor [3]. The water, dizziness and feeling cold [19]. In most cases, the reasons for this were economic factors and an improper symptoms of decompression occur after 6 hours and they knowledge of safe diving procedures. Traditional divers use often occur within the first hour after diving [5]. The length a compressor as an alternative [12]. The results showed that of time spent while diving in a stressed environment is one all of the traditional divers did not use complete health and of the risk factors for the occurrence of diving disorders, safety equipment. This is one of the factors causing disease especially decompression [20]. or disorders due to diving. There is a significant relationship All of the participants felt the economic burden as between the use of personal protective equipment and the a result of their health problems. After the participants expe- incidence of decompression [13]. rience paralysis, they are unable to work. Spending money The other supporting factor for health and safety be- increases for the treatment of disease. This can be a new haviour was “sesajen”. Traditional divers generally prepare economic burden for the family. Because of the economic “sesajen” before going diving as a form of surrender to God. burden, the participants chose traditional medication from It asks for abundant marine products and they can avoid a healer. Self-medication was the first action taken by the catastrophe while diving. “Sesajen” consists of the food, individuals in developing countries to deal with the disease leaves and water [14]. [21]. Traditional therapies used include salt compresses, trampling therapy on the seabed, and treatment such as Impact of occupational health using sago palm fronds to hit their paralyzed legs. and safety behaviour Health problems such as hearing loss, joint pain, and Behaviour after being affected paralysis were reported as being experienced by all partici- The participants, after experiencing the effects of diving, pants. The data showed that 29.8% suffered from joint pain, choose to stop and some continue to become traditional 39.5% suffered from hearing loss, and 10.3% suffered from divers after some consideration. The participants who de- paralysis [15]. Hearing loss is caused by the failure of the cided to stop did so because of health and trauma consid- process of the middle ear pressure to equalise to changes erations. Trauma is emotional and psychological pressure in environmental pressure. The diving technique used by because of unpleasant events or experiences. Participants traditional divers involves diving by holding their breath and who continue to be divers with consideration will undertake taking air from the surface of the seawater. The air then health and safety planning before diving. Individual actions flows into the compressor [3]. Decompression increases to prevent disease are driven by the seriousness and threat with many factors such as temperature, especially cold of disease to their health [22]. Perception about the severity temperatures [16]. of the threat of disease gives rise to a perception of self-vul- Several of the participants also experienced paralysis. nerability. Understanding vulnerability encourages people to This was related to the characteristics of the participants adopt healthier behaviours [23]. The higher the perceived in the form of spending a long time becoming a traditional risk, the higher the chance of engaging in behaviour to diver. The time from becoming diver can determine the reduce the said risk. length of a person’s exposure to the risk factors [3, 17]. The longer a person works as a diver, the more they are ex- CONCLUSIONS posed to a hyperbaric environment which can cause health This research shows that the health and safety be- problems such as paralysis [18]. In addition, diving without haviour of traditional divers is sparked by the participants’ preparation such as a certain level of bodily fitness also perceptions of the risks of diving on their health. This is contributes to the risk of paralysis. Participants who have supported by the internal and external reinforcement fac- a history of illness or disability have a risk that is 15.9 times tors of participants. Their perceptions and any reinforcing higher when it comes to experiencing health problems that factors ultimately shape the health and safety actions of the can lead to paralysis [18]. The age of the diver can also be divers. Diving without a plan, using only a compressor and a contributing factor to paralysis. Most of the participants “sesajen” has an impact on the health of the participants. were aged over 35 years old. The ideal age limit for diving The impact is experienced in the form of health problems, is 16–35 years old, while those who are younger than paralysis and economic burden. After being affected, the 16 years old or older than 35 years old have higher risks participants choose to stop being a traditional diver. Some when diving [18]. choose to remain a diver with the consideration of making All of the participants had done more than 12 hours of plans before diving. Health and safety when diving must diving without a resting phase. The longer the time spent be socialised and facilitated. The development of a diver’s

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www.intmarhealth.pl 61 Int Marit Health 2020; 71, 1: 62–70 10.5603/IMH.2020.0013 www.intmarhealth.pl review article Copyright © 2020 PSMTTM ISSN 1641–9251 Follow-up of citations of maritime epidemiological injury studies

Olaf Chresten Jensen1, 3, 4 , Agnes Flores2 , Fereshteh Baygi1 , Despena Andrioti Bygvraa1 , George Charalambous3

1Centre of Maritime Health and Society, Department of Public Health, University of Southern Denmark, Esbjerg, Denmark 2Caja Seguro Social, Rep. of Panamá, Vacamonte, Panama 3Graduate School, Frederick University, Nicosia, Cyprus 4School of Medicine, University of Panama

Abstract Background: The article is based on a review and follow-up of the citations of 13 epidemiological studies that aimed to improve maritime health and safety. While it’s well-recognised that epidemiology is needed in occupational health and safety, the main research question: “How can epidemiology help workers to return healthy from the sea” was unanswered. Materials and methods: The 13 articles were selected as a representative sample of different epidemiological design studies intended to contribute to improving safety management in fishing, merchant shipping and offshore industry. The PubMed, Research Gate, Cochrane-Library and Google Scholar were searched for authors that had cited our articles by using full bibliographic information and the results analysed. Results: In all, 213 citation records were identified. After duplicates and records with insufficient information were removed, 123 full-text articles were eligible for evaluation with answers to the research questions: how did other authors use the studies, how has the injury epidemiology been developed, which recommendations are given for new policies and new studies and how can epidemiology help workers return safe and healthy from the sea? Conclusions: The answer to the main research question is yes, epidemiological studies are not only useful but a necessary component by providing the needed evidence for successful prevention programmes. (Int Marit Health 2020; 71, 1: 62–70) Key words: epidemiology, injury, fishing, seafaring, citations, maritime

INTRODUCTION industry. The studies are for the main part based on the The review is based on 13 published articles that aim to Danish fishermen and seafarers and some of them are from improve the safety in the maritime sector and a follow-up of international collaborations. the citations by other authors in published studies. Concerning the study populations, there are about While epidemiological studies in the maritime health and 1.6 million merchant seafarers and 35 million fishermen and safety domains were rare until the 1990s, these studies they together with the offshore workers contribute to a sig- can be seen as pioneering in the maritime injury epidemi- nificant part of the European and the global economy [1]. ology. The method of follow-up of the citing articles is a new Important common characteristic for merchant seafarers, method that is supposed to improve the methods and to fishermen and offshore workers is that they are away from find new results. home, staying on the ships and oil platforms at sea for Each of the selected collection of 13 studies highlights weeks, months and even half of years. This poses some some specific design studies in injury epidemiology (Table 1). specific living and working conditions that is supposed to The articles represent different types of study-design like have some significant health impact in a short- and lon- register-based cohorts, cross-sectional questionnaire stud- ger-time perspective. ies, case-referent study based on registers of injuries in While epidemiology of diseases has been developed seafaring, fishing and offshore workers in the oil and gas over more than 100 years, the practice of occupational

Dr. Olaf Chresten Jensen, Centre of Maritime Health and Society, Institute of Public Health, University of Southern Denmark, N Bohrs Vej, 6700 Esbjerg, Denmark, * e-mail: [email protected] 62 www.intmarhealth.pl Olaf Chresten Jensen et al., Maritime injury studies

Table 1. Summary of the selected studies for review

Materials Methods Main results 1. Mortality and injury 1. Jensen (1996) Danish commercial fishermen Cohort study. Standardised mor- High mortality due to accidents, Mortality in fishing 1970–1985 compared to all tality ratio was calculated from and increased risk from cancer, economically active men (60974 the death register and population respiratory and cardiovascular fisherperson-years (375 deaths) housing data diseases 2. Jensen et al. (2014) Scientific articles and reports from The original incidence rates were Fatal injury rates decreased by Fatal accidents in fishing the maritime authorities in 8 Nor- recalculated as per 1000 person around 50% due to implemented review study thern countries 1990–2014 -years for international comparison safety programmes of the trends 3. Jensen et al. (2014) A literature review was performed Search and examining PubMed, Non-fatal injuries offshore decre- Fatal and non-fatal injuries by literature search and by exami- Embase, Google Scholar and ased. The few epidemiological in the offshore oil and gas ning national databases Web of Science studies does not allow for firm production conclusions 2. Injuries in fishing 4. Jensen et al. (2005) The work processes were described The injuries were coded according Preparing, shooting and hauling of Classification of working and classified in 17 main and up to to the developed classification the gear constitute about 50% of processes 13 subsidiary work tasks (n = 550) system all injuries 5. Jensen et al. (2006) Time measurements for the Injury reports in a 5-year period Especially high risk for embarking Injury and time studies 17 main and 13 subsidiary working were allocated to the specific and disembarking but also for processes analysed during fishing working processes and risk index other work processes trips in 4 vessel types numbers calculated 6. Jensen (2006) The reported injuries (n = 550) to A case-referent design with sam- The variations in the odds ratios of Injury risk at work processes the National Maritime Authorities ples of person-time as denomina- the fishermen continuously shift for 5-years defined the cases tor and the reported injuries as the between low and high-risk work nominators processes 3. Injuries in seafaring 7. Jensen et al. (2004) A pilot study was conducted Self-reporting duty period was Self-report of the duration of the Self-reported injuries (n = 1068) in Finland, Denmark, compared with information from latest tour of duty is useful for — evaluation of data validity the Philippines, Croatia and the crew register of the Maritime seafarers from merchant ships Spain using self-completed Authority but not for ferries questionnaires 8. Jensen et al. (2005) A questionnaire study was carried Multivariate analyses were used Occupational safety was the lowest Subjective assessment out in 11 countries (n = 6461) to analyse the occupational safety among ratings, seafarers < 30 years of safety seafarers who attended a regular on board, hazardous exposures of age, in the engine rooms health examination and the use of personal protection and dry cargo ships equipment 4. Slips, trips and falls (STF) 9. Jensen et al. (2000) Fishing injuries (n = 582) treated The proportion of fall injuries in The proportion of fall injuries in Slips, trips and falls at the emergency ward and registe- different age groups, injury types different age groups was U-shaped. in fishing red in the Nordic Medic Statistical (body lesions) and the injury me- STF injuries was 25% of all Committee (NOMESCO) system chanisms were analysed 10. Jensen et al. (2000) A questionnaire study was carried The seafarers gave information 43% were STF related. The high Slips, trips and falls out in 11 countries (n = 6461) on whether they were injured proportion of STF injuries came by in seafaring during their latest tour of duty, and use of a specific question, was it whether STF preceded the injury a STF? 11. Jensen et al. (2010) Fishermen tested new boots with Questionnaires at baseline and The new boot had significant better Reduction of slips trips anti-sleeping soles and tried them after half a year to determine the comfort and feeling of firm grip in fishing by intervention out under active fishing for half comfort and possible reduction when standing and walking a year (n = 161) of STF 5. Working conditions at sea 12. Jensen et al. (2006) Seafarers in 11 countries (n = 6461) The questions concerning the most Most seafarers worked every day Working conditions responded a questionnaire at the recent tour of duty self-rated health of the week, and on average for in seafaring health examinations in the seafa- status and the main characteristics 67–70 hours a week during pe- rers’ clinics of working conditions riods of 2.5–8.5 months 13. Jensen et al. (2014) Seafarers from 5 countries (n = 127) The questions concerning their A significant part of the seafarers Social security for completed a questionnaire at the knowledge about their social comes from the poorer countries seafarers health examinations in the seafa- security status on coverage without good social security rers clinics for disease and retirement systems

www.intmarhealth.pl 63 Int Marit Health 2020; 71, 1: 62–70 epidemiology was nearly non-existent until 1990 and the Inclusion criteria of the citing articles development of injury epidemiology and especially in the The first step was to systematise and analyse the citing maritime setting has been a challenge. One of the main articles and to define the eligibility criteria for the citation challenges is how to get valid nominator and denominator articles to be included. All types of epidemiological design, data to yield unbiased epidemiological rates-ratios. Over the in English or Spanish were included: literature reviews, latest decennia we have introduced the term “injury” for the cross-sectional, cohort and case-control studies. Only peer body damage and “accident” for the preceding incident [2]. reviewed scientific articles were included. An injury can be defined as a sudden event (caused by an accident) in which an external noxious agent hurts or injures Exclusion criteria of the citing articles a person. The epidemiological studies of occupational in- Articles or thesis in languages not understood by the juries were sparse until the nineteen eighties and injury author, like Indonesian, Chinese, Finnish or other languages studies had low interest among the epidemiologists. are excluded. Administrative reports are excluded.

The research questions Ethical issues How did other researchers use the studies? The review work does not involve any personal partici- Which recommendations for preventive policy and preven- pant and company information, and so the study does not tion are there? involve ethical problems. All data is processed according Which recommendations are given for new studies? to the medical duties act, as well as the guidelines for good How was the maritime occupational injury epidemiology epidemiological practice is followed. further developed? How can epidemiology help workers to return healthy from RESULTS the sea? In all 213 citation records were identified through database searching and additional free records were identified MATERIALS AND METHODS through other articles. After removal of 17 duplicates and The methods used in the 13 articles involved a transition 22 records with insufficient information, a total of 199 re- from epidemiological descriptive design to more advanced cords remained for screening. Of those 76 were excluded statistical methods in the studies. The studies are divided due to either lack of full text or other problems. The final in five sections: 1. Mortality and fatal injuries; 2. Injuries 123 full-text articles were eligible for evaluation (Fig. 1). in fishing; 3. Injuries in seafaring; 4. Slips, trips and falls; Twenty-five were included in the quantitative synthesis and 5. Working conditions at sea. 90 studies in the qualitative synthesis the articles are distrib- The 13 articles were selected as a good representa- uted in the five main sections: mortality and fatal accidents, tive sample of studies contributing to an epidemiological injuries in fishing, injuries in seafaring, slips, trips and falls analysis of the occupational risks to improve the safety and working conditions in seafaring. The citing articles that management in fishing, merchant shipping and offshore used this study as background with no further comments industry. Since the aim of this study was to analyse are kept out of this review. descriptive studies in health and safety in fishing, the Study 1: Mortality in Danish Fishermen [3]. The study criteria were set to achieve this aim. The whole process aimed to investigate the mortality patterns in Danish com- of search and selection of the citing articles is shown mercial fishermen (1970–1985), compared to all eco- in Table 2. nomically active men by the use of standardised mortality ratio with 95% confidence intervals for all causes among Search for the citing articles crewmembers was increased for accidents, ischaemic One by one, the 13 articles in the collection were heart diseases, bronchitis and emphysema compared to searched in PubMed Google Scholar by using the full all economic active men. Of the 13 citations, 3 studies for bibliographic information e.g. “Jensen OC. Injury risk comparison: [4, 5]. at the work processes in fishing: a case-referent study. Study 2: A review of fatal accident incidence rate trends European Journal of Epidemiology. 2006; 21(7): 521. in fishing international [6]. The review is based on scientific The searches were repeated in PubMed, Cochrane and journal articles and some few technical reports from the Research Gate to see if more citing articles come up. The maritime authorities in Poland, United Kingdom, Norway, citing articles were searched from 1st October 2017 to Iceland, Denmark, United States and Alaska and Canada. 31th October 2018. The follow-up time for the sample of The risk of fatal injuries was reduced by around 50% to the citations varies from the first publication in 1996 to an average of about 1 per 1000 person-years. The safety the latest included in 2014. programmes seem to have good effects, still the risk is

64 www.intmarhealth.pl Olaf Chresten Jensen et al., Maritime injury studies

Table 2. Search and selection procedure of the citing articles

1. Search each of the 13 articles in the databases mentioned by using the full bibliographic information in Vancouver style to identify articles that have cited one or more of the 13 articles 2. Search each of the citing articles one by one in PubMed and/or Google Scholar, and to be registered in 13 separate Zotero bibliographic databases 3. The full-text of citing each article are then searched in PubMed and/or Google Scholar or Research Gate and included in the Zotero database 4. Revise the citing articles one by one, delete duplicates and mark those with and without full-text 5. Exclude citations of no relevance (based on abstract or full-text) foreign languages and not maritime health 6. Evaluate one by one the full text of the citation articles, search for “Jensen” and copy the cited texts articles 7. Copy the citations with “snapshot” and paste them in the “Citation Archives” for evaluation 8. Classify the copied information according to the 5 classification points in PRISMA: doublet, exclusion of other reason, quantitative/ /qualitative useful, full-text/non-full text in (Liberati et al. 2009) 9. Construct a “selection tree” scheme for each of the 13 articles 10. Transfer the results to a sum scheme for all the 13 articles (Fig. 1) 11. Analysis, systematise and sum up the relevance of the citations in the Results section 12. Answers the research questions based on the 13 selected articles and the citing articles 13. Sum up in the conclusions on the gained new knowledge on methods and evidence for new prevention policies 14. Sum up the recommendations from the 13 articles and the citing articles about the needed prevention, policies for prevention and for new research

213 records identified through database searching

Identification 3 additional records identified through other sources

216 total records identified

17 duplicates removed

Selection 22 records with insufficient information for screening were removed

199 records remain for screening

22 with non-full text 54 full-text articles excluded of diff reasons excluded with diff reasons

Eligibility 122 full-text articles assessed for eligibility

90 studies included 25 studies included in qualitative synthesis in quantitative synthesis

Figure 1. Selection tree of the “citing articles” included in the review about 25 to 50 times higher than for onshore workers. Of the preventive programmes effect [7]. The fatal injuries in the 13 citations, 5 were excluded, 2 doublets, 2 were used the oil and gas production in the US are seven times higher as background references and 3 for comparison of the than for other workers in the US and the rate increased. quantitative results. Study 4: Classification and coding of commercial fishing Study 3: A review of epidemiological injury studies in the injuries by work processes: an experience in the Danish oil and gas offshore industry with the objectives to evaluate fresh market fishing industry [8]. This study was an answer

www.intmarhealth.pl 65 Int Marit Health 2020; 71, 1: 62–70 to the lack of a detailed classification system for fishing Study 9: Non-fatal occupational fall and slip injuries among accidents and relates closely to Study 3. The objective commercial fishermen analysed by use of the Nordic Medic was to describe all main work processes to create a new Statistical Committee (NOMESCO) injury registration system classification system to be used for injury prevention. The [13] in order to add more detailed information about slips, working processes were described and a classification cat- trips, and falls on board fishing vessels. Data on fishing injuries alogue with 17 main categories and up to 13 associated treated at the emergency ward at Esbjerg Central Hospital was subsidiary categories for each of the fishing methods were registered in the NOMESCO injury registration system [14] and prepared. All fishing injury reports to the Danish Maritime 38 authors cited the study. authorities for 5 years were coded according to the specific Study 10: Non-fatal occupational injuries related to slips, type of vessel and the specific working process where the trips and falls in seafaring [15]. Merchant seafaring often injuries happened. The study was cited by 15 authors in the involves hazardous occupational operations and several introduction of their studies and discussed in other studies. studies have shown increased fatal injury incidence often Study 5: Injury and time studies of the working process- related to slips, trips and falls on board and falls overboard es in fishing. The objective was to solve the methodical [16, 17]. In all 27 authors cited the study. problem that the use of a common overall denominator, Study 11: Reduction of slips, trips and falls and better e.g. days at sea related to different working processes on comfort using new anti-slipping boots in fishing [18]. One board is not useful to estimate the incidence rates for the hundred and fifty fishermen participated in the study with specific working processes. To solve the problem there was a baseline questionnaire and repeated the questionnaire a need to estimate the more precise use of working time for after they had used the new boots for half a year. The result specific working processes in typical types of professional was that the new boots were considered as much better or fishing. The working time for the specific working processes somewhat better by 90% of the fishermen reporting they in fishing was related to the number of injuries related to had a good grip on the deck and a feeling of standing firmly. the same working processes [9]. The study was cited by In all 6 authors cited the study 15 authors in the introduction of their studies but also in Study 12: Working conditions in international seafaring the discussion of some of the studies. [19]. The objective was to describe the self-rated health and Study 6: Injury risk at the work processes in fishing: the main characteristics of the seafarers working conditions. a case-referent study [10]. The aim of the study was to A total of 6461 seafarers in 11 countries responded to estimate the injury rate-ratios for the main work processes a questionnaire concerning the most recent tour of duty. in commercial fishing. The problem is that epidemiological In general, the seafarers’ self-rated health was good, but it studies describe the incidence ratios only related to the declined significantly with age. 20 authors cited the study, main strata in the industries, while the injury incidence ratios Study 13: Social security for seafarers globally [20]. The for the specific work processes within the workplaces have seafarers completed a short questionnaire concerning their not yet been studied. The study was cited by 12 authors in knowledge about their social security status. The significant the introduction of their studies but also in the discussion disparities in the social security coverage were pointed out of some of the studies. among the nationalities. The solutions suggested are to Study 7: Self-reported injuries among seafarers. Ques- implement the minimum requirements as recommended by tionnaire validity and results from an international study the International Labour Organisation 2006 Convention, to [11]. The aim was to test the method of self-report of injuries survey the implementation and in the long term to struggle and length of time at risk during the latest duty period and for a global social equality. The only one citation was from second to study the injury incidence rate among seafarers one of the co-authors. by use of the method. 32 authors cited the study. Study 8: Subjective assessments of safety, exposure DISCUSSION to chemicals and use of personal protection equipment This is to our knowledge the first study to follow-up on in seafaring. The objective was to describe the seafarers’ how other authors have cited and used a sample of studies. assessments of the occupational safety on board, their Contributions from the citing articles to the main research exposure to chemicals and the use of personal protection questions are identified and discussed. equipment and to identify the areas for further risk assessment and preventive measures [12]. A questionnaire How did other researchers use study was carried out in 11 countries among seafarers who the studies for comparisons? attended a regular health examination. The study was cited In contrast to our Danish Study 1, the Swedish fisher- by 11 authors, some in the introduction and others in the men had lower mortality rates from: all causes, malignan- discussion of their studies as commented in the discussion. cies, respiratory and cardiovascular diseases compared to

66 www.intmarhealth.pl Olaf Chresten Jensen et al., Maritime injury studies other men [4]. The similar pattern was found for Finnish days at sea in order to obtain precise denominator data fishermen with lower mortality from: all causes, ischemic for calculation of the Incidence risks and relative risks the heart diseases, cerebrovascular diseases and malignant first time. The subjective assessment of safety, exposure neoplasms than the general population [5]. Study 4 and to chemicals and use of personal protection equipment in 6 on classification and coding of injuries by the work pro- seafaring in an international setting was documented for cesses was followed by several other authors: Syron et al. the first time in Study 8. A solution to the methodological [21] utilised our system to code non-fatal injury cases to problems by using proportionate risk estimates in Study point out the most frequent work processes associated with 9 was proposed by multiplication the proportions with the non-fatal injuries. Krenz et al. [22] also found the “Jensen” estimates of the incidence rates of all injuries [34]. Based on System useful for activity classification for claims. Lucas et the learning from the NOMESCO Study 9, the seafarers were al. [23] applied a framework based on our system to code asked specifically whether slips trips and falls preceded the processes specifically related to long-liners and trawlers. occurrence of the injury in Study 10. The method was new McGuiness and Piniella et al. [24] points out the need for and not surprising that injuries related to STF on merchant specific classification of the working processes for more ships were more frequent than the previous estimates. effective prevention [25]. The experiment of the use of good footwear for fishermen Study 7 on self-reported injuries among seafarers was in Study 11 was new and commented by various authors. used by among others Shan [26]. Study 9, on the occupa- In the development of epidemiology, we have moved from tional fall and slip injuries in fishermen coded according to Haddon’s Matrix to the modern epidemiological sociolog- the Nordic Medico Statistical Injury Registration System was ical model of the ethology to be used for prevention. We used by Bull et al. [27] who found similar high percentages have also moved excellently forward since the era where of slips, trips and falls in fishing. Study 10 on slips, trips and “accident” epidemiology was not recognised as scientific falls (STF) in merchant seafaring was followed by several discipline e.g. that injury epidemiology is nearly absent [35]. authors confirming that STF related injuries especially in the engine rooms need to be taken in attention for better Which recommendations for preventive prevention [28, 29]. Study 11 on the fishermen’s test of new policy and prevention are there? boots with anti-slipping soles was commented by Lucas et Based on the trend’s analyses of fatalities in fishing in al. [30] who mention the resistance to introduce new type of Study 2, the preventive programs seem to have good effects. footwear and that good footwear can hinder falls overboard Still, the authors call for continued effort to improve safety and save life’s [30–32]. in fishing in all the studies [23, 30, 36]. According to the authors comments on Study 4, 5 and 6 How was the maritime occupational the analysis of the specific risk at the different work process- injury epidemiology further developed? es is recommended to identify hazardous tasks [21]. Future Study 1: The methods used in epidemiology have prevention efforts should target work processes associated changed radically from using paper forms to pure digitalised with the most frequent and most severe injuries by using data over the latest half century. This great development in time estimates for work processes in order to determine the epidemiology permits to handle big amount of data with risk estimates. advanced statistical methods, especially the multiple regres- Our proposal of the need for better trauma prevention on sion analysis [33]. Study 2: The review of fatal injuries in board in Study 7 was supported by several authors [37–39]. fishing [6], shows an overall decrease of the fatal incidence The main recommendation from Study 11 is to encourage rates over the last decades. The study showed that trends fishermen to replace their boots as soon as they are worn can be compared for the first time with meaning for the out and that risk assessments of fishing vessels should planning of the prevention activities. In Study 5 and 6, the include assessment of footwear. The recommendations injury and time studies of the working processes in fishing in study 12 include that further studies are necessary to was new and opens up for a more specific and effective describe more closely the influence of work schedules on prevention of the injuries in fishing. The aim was to estimate the health and social life of seafarers. Patella et al. [40] cite the relative risks for specific working processes in order to us because we supply the documentation that the engine focus the prevention on the specific work processes. The crew suffer the highest overall levels of stress followed by use of the case-control study design in occupational injury the deck and engine officers. Österman and Hult [41] cite studies is rare and the new method by using the samples us because we say that the seafarers work and live be- of time for the work processes as the denominators is new. tween 2 to 8 months on board continuously exposed small The injury epidemiology in merchant seafaring was further possibilities for recreation together with people of various developed in Study 7 by asking for the precise number of backgrounds and nationalities.

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Oldenburg et al. [42] again refer to our study to find out The gap of knowledge remains and calls for more studies. the very long stay on board after 10 months on the condi- It is also worth mentioning that qualitative studies should tions with permanent physical factors noise and vibration be used for further investigation in this area. post on the working and leisure time has a physical and mental effect on the quality of life. Rydstedt et al. [43] again How can epidemiology help workers refer to our study concerning the engine room personnel to return healthy from the sea? with the highest mental health problems. Oldenburg and The study examples illustrate how the evidence from Jensen [44] 2012 support and cite our study about the epidemiology contributes to identify the relative risk of extreme work press also mention that we found nearly 70 fatal and non-fatal injuries and diseases. work all hours per week for both officers and none officers In this way the studies are necessary as contributing per week. In Study 8, the use of personal protective equip- components to successful prevention. ment was assessed to be too low among some parts of the This is consistent with the definition of epidemiology crew and in some working areas and types and sizes of as being “the study of the distribution and determinants of ships. Several authors cited our article and agreed there health-related states or events (including disease), and the is a need to improve the safety and the prevention of the application of this study to the control of diseases and other risks on board [45–47]. health problems” [48, 49]. The five steps to risk assessment are carried out by using knowledge from research about the Which recommendations are given risk in general and knowledge about what is the best pre- for new studies? vention. The risk assessment comes from observations and Several studies underscore the lack of international from epidemiological knowledge about the risk in number requirements to harmonise the registration of injuries and severity. Proposals for effective prevention measures in fishing for prevention [24, 48]. In Study 7 it was con- also come from epidemiological research. cluded that subjective data about the length of the tour If the evaluations show there is no or too little effect for calculating the incidence rates is useful for merchant of the prevention measure we need to amend the preven- ships but not for ferries and other type or permanent em- tion type and repeat the evaluation process once more. ployment. When the seafarers have permanent contracts Seen from a global perspective there is an urgent need specifying the number of hours or days per year, this can to help with epidemiology for fishing and aquaculture in be used for denominator data for calculation of the injury the developing countries, e.g. Latin American and African incidence rates. Study 9: By using the NOMESCO system countries [50]. for occupational injuries from falls and slips (STF) some important new issues in the injury epidemiology was real- CONCLUSIONS ised. The estimated proportion of STF-injuries was more The studies have been useful and contributed to obtain precise and higher than seen before. An analysis based better safety in fishing and seafaring and contributed with on the free text in the NOMESCO register files, revealed new methods in injury epidemiology. The main research that one fourth of the injuries are related to falls/and slips question whether epidemiology can help the workers and thus preventable and constituted 60% of all injuries to get home safely from work is answered with a “yes”. to the chest. And then it was realised that giving specific The studies are needed to establish an optimal prevention attention to STF-related injuries will give the most precise planning like architectural plans are needed for successful estimate of STF-injuries for the prevention. To avoid a pos- building construction. To avoid biased results the epidemi- sible misclassification and underestimation of STF-injuries ological studies, need to be conducted under the highest it was recommended to include an extra specific variable: scientific standards. whether falling or slipping preceded the crash phase of The developing countries pose a specific challenge the injury or not. This was utilised later in the international for the epidemiology in fishing and aquaculture with mil- questionnaire study among seafarers [15]. Based on the lions of workers in the poorest countries. A supposed high Danish and the Norwegian studies, the NOMESCO system incidence on fatal and non-fatal injuries needs urgently was found useful for analysis of fishing injuries by data to be documented for political attention and effective from the emergency rooms. Still, there is no information prevention. recorded about the working process, which hinders for In a global perspective new emerging risks continue effective use in the practical prevention, and this was to occur, and surveillance programmes of health and the subject for the other studies. Study 12 on the social safety are needed and should be developed based on security for seafarers was not followed by other studies. the documented risks from the studies.

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70 www.intmarhealth.pl Int Marit Health 2020; 71, 1: 71–77 10.5603/IMH.2020.0014 www.intmarhealth.pl ORIGINAL ARTICLE Copyright © 2020 PSMTTM ISSN 1641–9251 Temporary and permanent unfitness of occupational divers. Brest Cohort 2002–2019 from the French National Network for Occupational Disease Vigilance and Prevention (RNV3P)

Richard Pougnet1, 2, 3, Laurence Pougnet2, 4, 5, Jean-Dominique Dewitte1, 2, 3, Brice Loddé1, 2, 6, David Lucas1, 2, 6

1Centre for Professional and Environmental Pathologies (Centre de Ressource en Pathologie Professionnelle et Environnementale CRPPE), Brest University Hospital (CHRU), Brest, France 2French Society for Maritime Medicine, France 3Laboratory for Studies and Research in Sociology (LABERS), EA 3149, Faculty of Humanities and Social Science (Faculté de Lettres et Sciences Sociales), Victor Segalen, European University of Brest, Brest, France 4Medical Laboratory, HIA Clermont-Tonnerre, CC41 BCRM Brest, Brest, France 5Host-Pathogen Interaction Study Group (Groupe d’Étude des Interactions Hôte-Pathogène GEIHP), EA 3142, European University of Brest, Brest, France 6Optimization of Physiological Regulations (ORPHY), EA 4324, Faculty of Science and Technology, European University of Brest, Brest, France

Abstract Background: In France, the monitoring of professional divers is regulated. Several learned societies (French Occupational Medicine Society, French Hyperbaric Medicine Society and French Maritime Medicine Society) have issued follow-up recommendations for professional divers, including medical follow-up. Medical decisions could be temporary unfitness for diving, temporary fitness with monitoring, a restriction of fitness, or permanent unfitness. The aim of study was to point out the causes of unfitness in our centre. Materials and methods: The divers’ files were selected from the French National Network for Occupatio- nal Disease Vigilance and Prevention (RNV3P). Only files with a special medical decision were selected, between 2002 and 2019. Results: Three hundred and ninety-six professional divers are followed-up in our centre and 1371 medical decisions were delivered. There were 29 (7.3%) divers with a special medical decision, during 42 (3.1%) medical visit. Twelve (3.0%) had a permanent unfitness. The leading cause of unfitness was pulmonary diseases: emphysema (3), chronic obstructive pulmonary disorder (2), asthma (2). Sixteen (4.0%) divers had temporary unfitness. The leading causes were cardiovascular (4 times) and neurological (6 times). Twelve (3.0%) divers had had at least one decompression sickness. Conclusions: Judgments of permanent unfitness for diving were rare (3.0% of divers), but were because of life-threatening disease. Medical follow-up of occupational divers was justified to decrease the risk of fatal event during occupational dives. (Int Marit Health 2020; 71, 1: 71–77) Key words: diving, occupational medicine, decompression sickness, France, contraindications

Dr. Richard Pougnet, MD, PhD, Centre for Professional and Environmental Pathologies, Morvan Teaching Hospital (CHRU Morvan), 2, av Foch, 29200 Brest, France, * e-mail: [email protected]

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INTRODUCTION The files of the 396 professional divers are recorded in Many professions include underwater activities, expos- our centre. The divers’ files were selected from the French ing employees to hyperbaric constraints. In France, for ex- National Network for Occupational Disease Vigilance and ample, professional divers may be scuba divers, carrying out Prevention (RNV3P). The data were collected anonymously construction, repair or building supervision work; aquarium on a CHRU computer, requiring no authorisation from the officers, working on the technical side of facilities, or as vet- National Commission on Informatics and Freedom. Patients erinarians and caretakers; or scientists carrying out fauna had given their prior consent for any anonymous retrospec- or flora surveys, or geological or oceanographic studies. tive studies of their medical data. Many other professions also include underwater activities, To be included in the study, divers had to have been such as coast guard work or fishing [1]. seen at least once in our centre, between 2002 and 2019, Professional divers are thus exposed to several types of for a professional diving aptitude visit (initial visit before be- risks. Depending on their specific profession, they may be ginning a professional diving career or follow-up visit during exposed to risks related to biological, chemical or psycho- the diving career, according to the regulations in force in logical hazards, etc. [2, 3]. All professional divers are also France); divers also had to have had a particular restriction subject to the risks associated with diving in water, as are (depth, type of gas, temperature etc.) or been found tem- recreational divers. The literature reports many risks for div- porarily or permanently unfit for professional diving [14]. ers, whether professional or recreational. On the one hand, Divers who had not come to the centre for a professional we have the risk of developing a pathology related to hyper- diving follow-up consultation were excluded (i.e., those who baric stress, such as dysbaric osteonecrosis, decompression had come for advice on recreational diving), as were those sickness, thoracic barotrauma or barotraumatic otitis, and who came for a professional diving visit and were given an many other pathologies [4–7]. On the other hand, there is assessment of complete fitness for professional diving. also the risk of an accident occurring underwater, even if Files meeting the selection criteria were then manually the origin is not hyperbaric stress in itself. For example, analysed by a Centre for Professional and Environmental a fainting episode could lead to drowning. Pathologies (CRPPE) marine physician. Socio-professional Some of these accidents are therefore life-threatening parameters were collected: age, sex, body mass index, medical emergencies. This is particularly the case for de- smoking, regular alcohol consumption, and regular sports compression sickness or drowning [8–10]. Other patholo- practice. Medical histories and treatments were also col- gies involve long-term functional capacities, such as spinal lected. Professional and recreational diving profiles were cord injury or dysbaric osteonecrosis [11]. For this reason, compiled: length of professional and recreational diving many countries have regulations and recommendations practice, as well as the annual and lifetime number of dives, for the medical follow-up of professional divers [12, 13]. In average duration and depth. The focus was on the analysis France, the text regulating the monitoring of professional of pathologies that motivated a restriction or incapacity divers was adopted in 1991 and repealed in 2011 [14]. (type of pathology, link with diving), as well as the impact Since 2016, several learned societies (French Occupational on professional practice (i.e. permanent or temporary inter- Medicine Society, French Hyperbaric Medicine Society and ruption). From these data, it was possible to determine the French Maritime Medicine Society) have issued follow-up number of cases of decompression sickness (DCS) in our recommendations for professional divers, including medi- cohort, since all divers who had had DCS, with the exception cal follow-up and paraclinical examinations to be adapted of barotraumatic otitis, were seen again in our centre before according to the diver’s health status and diving profile [14]. resuming their professional activity. As in other countries, this type of approach is sometimes Data entry was done using Excel software, Microsoft questioned [15, 16]. The objective of this study was to Office 2017®. Averages and extremes were worked out on determine the conditions that led to a contraindication to this software. The correlation analysis of pathologies was a profession with hyperbaric stress, or to a restriction of diving done using Biostatgv®, by c2 test or Fisher test, depending techniques (type of gas, depths, etc.), and to determine on the validity parameters. which unfitness notices were issued in a centre carrying out professional diver fitness visits. RESULTS Description of the population MATERIALS AND METHODS Our sample included 29 divers, 22 (76%) male and This was a retrospective study of the Centre for Maritime 7 (24%) female. There were more women in our sample Health at the University Hospital (Centre Hospitalier Région- than in the source population (i.e. all divers followed in the al Universitaire [CHRU]) in Brest, between 1st January 2002 centre), but this was not significant: 7 (24%) vs. 69 (17%) and 31th July 2019. (p = 0.32). The average age at the time of the problemat-

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Table 1. Dive profiles according to type of dive (recreational or professional)

Type of dive Occupational dives Recreational dives Number of divers 22 13 Seniority [years] 9.5 (1–32) 7 (3–15) Number of dives per year 70 (10–250) 35 (2–100) Number of dives over lifetime 724 (10–4750) 264 (10–1000) Depth [m] 17 (5–50) 31 (7–50) Time [min] 64 (30–180) 70 (30–150) Data are shown as number or mean (extreme)

There were therefore 22 divers in professional activities, who made an average of 70 dives per year (extremes: 10–250 dives/year), and 7 divers were seen before the 3; 10% beginning of occupational diving (initial visit). Thirteen people were also engaged in recreational diving, two of whom 3; 10% also practiced snorkelling (Table 1). 10; 35%

3; 10% Medical decisions Medical decisions could be temporary unfitness for diving (19 times), temporary fitness with monitoring (7 times), 10; 35% a restriction of fitness (4 times), or permanent unfitness (12 times). The same diver may have had decisions of provisional fitness or provisional unfitness several times. This was the case for 7 divers. In total, the centre issued 42 such Scientist advisories, for 29 divers. There was a total of 1371 medical Technician visits for 396 divers. So 3.1% of medical visits found out Veterinarian a contraindication or a restriction to dive, and there was 7.3% Coast guard divers who had a contraindication or a restriction to dive. Other

Figure 1. Distribution od divers by trade Permanent unfitness for professional diving Twelve divers had a definitive contraindication to professional diving, representing 3.0% of the divers monitored at ic diagnosis was 37 years (extremes: 23–59 years). The the centre (12/396). There were 4 scientists, 1 veterinarian, average length of time in professional diving was 7 years 6 technicians (1 for scientific aquarium maintenance, 1 for (extremes: 0–19 years). For 7 divers, the health problem laboratories and 4 for underwater worksites), as well as was discovered during the initial examination, a regulatory a truck driver who had an initial visit. prerequisite at the beginning of the professional diving ca- Three out of these 12 (25%) divers had already had a tempo- reer in France. It should be noted that among these 7 divers rary restriction: 1 for a barotraumatic otitis; 1 for a work accident with contraindications to professional diving, 5 practiced with a whiplash injury; and 1 following the discovery of chronic recreational diving, with significant diving profiles: between obstructive pulmonary disorder (COPD) while the assessment 50 and 600 lifetime recreational dives (annual average of was being made, leading to the final contraindication. 30 dives per year), at depths of 30 to 50 m and durations Four out of these 12 divers (33.3%) were declared per- of 60 to 120 min. manently unfit for professional diving during their initial visit, even if 3/4 had been practicing recreational diving for 3 to Description of professional activity and 10 years. Lung pathologies were the main cause of perma- dive profiles nent incapacity: 8/12 (66.7%) of the cases of permanent The majority of divers either were scientists (e.g. biolo- unfitness (Fig. 2). Three of the divers had had decompression gy, oceanography, etc.) (10; 34%) or did different types of sickness at least once, including one diver who had suffered underwater work (10; 34%) (Fig. 1). alveolar haemorrhages several times during scuba dives.

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0 Pulmonary COPD Dysbaric Asthma Alveolar Acute Hyperoxic emphysema* osteonecrosis haemorrhage coronary convulsives syndrome crisis

Figure 2. Causes of definitive contraindication to professional diving; *one emphysema with pneumothorax; COPD — chronic obstructive pulmonary disease

Description of temporary unfitness ly of scientists, veterinarians, port infrastructure security and restrictions personnel and members of the coast guard. There are There were 19 provisional unfitness assessments, in- relatively few scuba divers working in deep water, or off volving 16 different divers (4.0% of all divers), often to shore. Similarly, this centre followed few fishermen, unlike have time to explore an anomaly found during the medical other geographical areas [17]. This study therefore did examination (Table 2). There were 10 restricted fitness not allow us to know the exact prevalence of DCS among notices for 6 divers (Table 3). divers in the regions of the west coast of France. These divers are often followed in other centres, such as those Description of decompression sickness in Paris, depending on their company’s headquarters. This cases was not the focus of our study. The purpose of this study Twelve divers out of 396 divers followed in our centre was rather to know the fitness limitations issued by our (3.0%) had had at least one DCS incident, including 2 divers centre and determine the pathologies that motivated them. who had had 2, resulting in a total of 14 DCS incidents. These pathologies included DCS, but such incidents did not Vestibular DCS was the most common (Fig. 3). represent the majority. It would also be unwise to estimate the prevalence of barotraumatic otitis based on this study DISCUSSION alone. Many divers are only seen once a year. In case of This united, focused, retrospective study provided in- barotraumatic otitis, the care circuit in France provides for formation on the prevalence of decompression sickness a consultation in the emergency room of a hospital (knowing among the 396 divers at this centre, and mainly, the dif- that there are 2 university hospitals and a dozen hospitals ferent types of medical opinions issued in the event of in Brittany), where they are treated by an ear-nose-throat a proven or suspected pathology that might increase the (ENT) physician. Temporary cessation of diving is generally risk in professional diving. Only 12 (3.0%) divers reported defined as a work stoppage prescribed by the ENT physician, having had a DCS incident. Similarly 12 (3.0%) divers had until the eardrum heals. In other words, not all divers with a permanent contraindication to the practice of a profes- a barotraumatic otitis necessarily return to our centre for sional activity in hyperbaric environments, mainly due to further consultation before resuming diving. Finally, it may pathologies of the respiratory system. And 16 (4.0%) divers seem surprising not to have any temporary unfitness for had a temporary inability to heal or to complete clinical and diving due to pregnancy, when 69 women were followed in paraclinical explorations of an abnormality discovered by this centre. This was also due to the care circuit in France: in chance during the medical examination. the event of pregnancy, work in a hyperbaric environment is This study had several limitations. By being carried out prohibited by the Labour Code. There is therefore no medical at a single centre, it represented the medical activity of advice for diving in the case of pregnancy. this centre and also concerned a very particular population In our centre, respiratory pathologies as a whole were of divers. The divers monitored in Brest consisted main- the leading cause of unfitness, due to the risk of decom-

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Table 2. Description of provisional unfitness decisions

Organ Pathology Further explorations Links with diving and objectives Number of occurrences of the medical opinion Cardiovascular Arterial hypertension: 3 times Cardiological exam, cardiac No link ultrasound, blood work Objective: avoid workplace injury Heart murmur Cardiological exam, cardiac No link Patent foramen ovale was ultrasound Objective: possible permeable oval foramen, the suspected: 1 time aim being to avoid DCS Neurological Vertigo: 2 times ENT and neurological opinions, Type 2 cochleovestibular DCS related to diving MRI Unfit for 6 months Paraesthesia of the lower limbs: Neurological opinion, CT, MRI Type 2 spinal cord DCS 3 times and electromyography Unfit for 6 months Epileptic seizure Neurological opinion, Epileptic seizure in an ethyl intoxication context 1 time MRI, EEG Unfit for 12 months ENT Barotraumatic otitis: 3 times ENT opinion Barotrauma related to diving Musculoskeletal Enchondroma: 1 time Abnormality of the humeral No link with diving diaphysis. CT and MRI, rheuma- Objective: eliminate osteonecrosis toid and orthopaedic opinions Unfit for 6 weeks Workplace dive accident: Operation Non-specific link whiplash injury: 1 time Unfit during 6-month recovery period Respiratory Suspicion of emphysema upon Thoracic CT scan No link X-ray: 2 times Objective: avoid pulmonary barotrauma Unfit 1 month TLCO disorders: 1 time Thoracic CT scan No link Objective: avoid DCS Haematologic Lymphoproliferative disorder: Haematological opinion No link 1 time Objective: understand the relative risk of DCS Unfit for 1 month CT — computed tomography; DCS — decompression sickness; EEG — electroencephalogram; ENT — ear-nose-throat; MRI — magnetic resonance imaging; TLCO — transfer factor of the lung for carbon monoxide

Table 3. Particular medical opinions

Medical opinion Clinical situation Number of medical advices Number of divers Provisional fitness with the objective of reducing Cardiovascular risk factors and risk calculation 6 advices; 2 divers modifiable factors: tobacco use, sedentary lifestyle, too high cholesterol Restriction: diving only with air, limited depth History of decompression sickness 2 advices; 2 divers Commencement of HIV treatment 1 advice; 1 diver History of asthma in childhood, persistence of 1 advice; 1 diver non-specific bronchial hyper-responsiveness HIV — human immunodeficiency virus pression sickness. Two divers (2/29) were declared unfit the risk of bronchospasm, which, on ascent, could result in for professional diving due to asthma, and 1 other received chest barotrauma. Some studies have shown this increased diving restrictions (diving with air, max. 7 m). Several factors risk for asthmatic divers compared to non-asthmatic divers were taken into account in these medical decisions. For [19]. However, the available literature does not support this a long time, asthma contraindicated diving, both professional hypothesis [18, 20]. For this reason, several countries have and recreational. Indeed, many studies have shown the risk updated their recommendations for recreational diving. In of bronchospasm. Recent analyses have shown that this France, asthma contraindicated professional diving until risk increases mainly in cold water or with depth [18]. Logic 2011. Since the 2016 recommendations, cases can be therefore seemed to indicate that asthma could increase considered individually, similar to the case-by-case approach

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pression sickness. Studies have shown that gas bubbles can pass through the PFO and cause stroke. People with a PFO are more likely to have strokes and migraines than others, including at atmospheric pressure. In our centre, we gave a judgment of fitness for diving to divers with a PFO 3 4 after transcatheter closure [25]. However, treating the PFO does not guarantee that no bubbles will pass through [26]. Before allowing diving to continue, especially for people 1 4 who have had a DCS, it seems reasonable to discuss the benefit/risks balance of an intervention on a case-by-case 4 basis [27]. It might be better for some divers to stop diving. The decompression sickness among divers in our centre was mainly vestibular and spinal cord DCS. Most of these divers were able to return to professional diving after tem- Otitis barotraumatic porary unfitness judgments lasting 6 to 12 months. It may Alveolar haemorrhage seem surprising that dysbaric osteonecrosis is more likely to Vestibular decompression sickness lead to permanent disability. The decision took into account Spinal decompression sickness Dysbaric osteonecrosis functional impact and recurrences. For example, the same diver had 2 dysbaric osteonecrosis. For central DCS, the decision to allow diving to resume was made based on the Distribution of decompression incidents Figure 3. origin of the accident. If there was no pathology exposing a diver to a risk of recurrence greater than the normal risk used with recreational diving. Medical judgments must then associated with diving, and if physical and psychological take into account the balance of asthma, the impact on recovery allowed it, the resumption of diving was possible. respiratory functional explorations and the type of diving. This was in line with the practices of other French maritime Three divers had emphysema and one of these three had medicine centres [28]. The deliberation weighed the impor- emphysema with a subpleural bubble; he had spontaneous tance of diving for the person and his socio-professional pneumothorax at home. Two divers had COPD. Studies integration, as well as the diver’s psychological state. The have not shown the development of obstructive ventilatory literature reports several studies on the psychological profile disorders due to diving, defined as FEV1/CV < 80% [21]. of divers. Van Wijk [29, 30] showed that the psychological The data available in the literature only showed decreases profiles of military divers have been stable in recent decades in peripheral bronchial flow rates and transfer factor of the in the literature. However, the author pointed out that these lung for carbon monoxide [22, 23]. results were not applicable to all populations. A study by It may seem surprising that temporary unfitness and/ Lafère et al. [31] analysed the behaviour of divers who had or specific fitness judgments were rendered 9 times with previously had a DCS. They found that some divers were respect to cardiovascular risks. The question arose here, unable to exercise caution when diving [31]. Further studies given the professional nature of the dives. Divers did not would be useful to determine how to predict whether divers have the flexibility to schedule their dives according to their will exercise caution. However, in our centre, we only fol- perceived “state of fitness”. The aim was to limit the risk lowed civilian divers. They practiced diving in a professional of cardiovascular incidents during a dive in people who setting, without always enjoying this exercise. Decisions do not have any particular physical training and a high could therefore not always be based on literature data. As cardiovascular risk. The aim was therefore to limit the risk it is often the case in medicine, this was a case-by-case of accidents and drowning [1, 14]. Recent literature also analysis, often carried out in consultation with the doctors reports the hypothesis of cardiovascular effects even if at the centre [32]. dives are of short duration [24]. Åsmul et al. [24] showed that divers who did more than 150 dives per year had CONCLUSIONS a higher risk of myocardial infarction than those who did fewer This study analysed the medical opinions during the than 50 dives per year: risk ratio 2.91 (confidence interval monitoring of 396 professional divers in a marine medicine 1.23–6.87). They also found a risk of high blood pressure centre. Judgments of permanent unfitness for diving were in former divers compared to the general population. rare (3.0% of divers). These opinions were motivated by the The case of unfitness for suspected patent foramen desire to avoid a diving accident. On 19 occasions, tempo- ovale (PFO) was part of an approach to preventing decom- rary unfitness rulings were issued, mainly in the months

76 www.intmarhealth.pl Richard Pougnet et al., Temporary and permanent unfitness of occupational divers following decompression illness to determine the origin aux contraintes hyperbares. Arch Mal Pro Env. 2016; 77(3): 414, doi: 10.1016/j.admp.2016.03.131. of abnormalities detected during medical examinations. 15. Sames C, Gorman DF, Mitchell SJ, et al. The impact of health Finally, 3% of divers had had an incident of decompression on professional diver attrition. Diving Hyperb Med. 2019; 49(2): sickness between 2002 and 2019. 107–111, doi: 10.28920/dhm49.2.107-111, indexed in Pubmed: 31177516. The results of these years of medical monitoring showed 16. Sames C, Gorman D, Mitchell S, et al. An evidence-based sys- that the French model made it possible to detect pathologies tem for health surveillance of occupational divers. Intern Med J. leading to a risk for divers, or pathologies caused by diving. 2016; 46(10): 1146–1152, doi: 10.1111/imj.13204, indexed in Pubmed: 27507783. 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[Safety and health protection 31. Lafère P, Balestra C, Caers D, et al. Patent Foramen Ovale (PFO), Per- of professional divers in the context of the European Diver Technol- sonality Traits, and Iterative Decompression Sickness. Retrospective ogy Committee (EDTC): technical training and diver competence, Analysis of 209 Cases. Front Psychol. 2017; 8: 1328, doi: 10.3389/ role of the “examining” physician]. G Ital Med Lav Ergon. 2003; 25 fpsyg.2017.01328, indexed in Pubmed: 28824507. Suppl(3): 249–251, indexed in Pubmed: 14979172. 32. Sames C, Gorman D, Mitchell S. Postal survey of fitness-to-dive 14. Lodde B, Meliet JL, Pougnet R, et al. Recommandations de bonne opinions of diving doctors and general practitioners. Diving Hyperb pratique pour le suivi en santé au travail des travailleurs exposés Med. 2012; 42(1): 24–29, indexed in Pubmed: 22437972.

Krzysztof Korzeniewski1, 2

1Department of Epidemiology and Tropical Medicine, Military Institute of Medicine, Warsaw, Poland 2Polish Society of Maritime, Tropical and Travel Medicine, Gdynia, Poland

Abstract Travelling has been growing in popularity over the last several decades. Eye diseases, e.g. decreased visual acuity, inflammatory or degenerative lesions, chronic diseases or eye trauma, affect all groups of travelers. The main risk factors contributing to the manifestation or exacerbation of common ocular diseases include exposure to dry air (inside the airplane cabin or in air-conditioned hotel rooms), exposure to chlorinated or salty water (swimming/bathing in swimming pools or in the sea), and sudden changes in the weather conditions. In addition, travelers to tropical destinations are at risk of ocular diseases which are rarely seen in temperate climate, e.g. onchocerciasis, loiasis, gnatostomosis, African trypanosomosis, or trachoma. The most common condition of the eye seen in travelers is conjunctivitis; it may be either of cosmopolitan (bacterial or viral infections, allergic inflammation) or tropical etiology, e.g. arboviral infections (zika, chikungunya). Given the fact that a large proportion of the general population have decreased visual acuity and many of them wear contact lenses rather than glasses, keratitis has become a common health problem among travelers as well; the major risk factors in such cases include sleeping in contact lenses, prolonged exposure to air-conditioning, working with a computer or swimming/bathing in microbiologically contaminated water (e.g. Acanthoamoeba protozoa). Conditions affecting the cornea, conjunctiva or lens may also occur due to excessive exposure to solar radiation, especially if travelers wear glasses without a UV protection. (Int Marit Health 2020; 71, 1: 78–84) Key words: eye diseases, travelers, treatment, prevention

EPIDEMIOLOGY group > 60 more than 80%). Among children under 15 years The World Health Organization (WHO) has estimated old, visual defect is seen in 50% of boys and more than 60% that over 280 million people globally are affected by visual of girls. In Poland, the most common diseases of the eye in- defect, of whom 14% have blindness and another 86% have clude cataract, glaucoma, age-related macular degeneration less severe ocular problems, e.g. decreased visual acuity or (AMD) and diabetic retinopathy. More than 800,000 Poles inflammatory conditions. The leading causes of sight defect (mostly patients over the age of 60) have cataract and this globally include refractive error and cataract (clouding of the number is likely to grow. In 2020, it is expected to exceed lens). The highest prevalence of eye conditions is reported one million cases in 38.5 million population. Clouding of the from China and India, i.e. the two most populous countries lens is more often seen in women (70% cases) than in men. in the world. Population ageing is considered the major risk Another common eye condition, i.e. glaucoma affects over factor for increasing prevalence of visual defect. More than 450,000 Poles, mostly women (70% cases), and the number 80% of the general population over the age of 60 years old of cases is constantly increasing. It is expected to reach has vision defect, usually presenting as decreased acuity over 600,000 cases in 2035. The data from the statistics in (presbyopia). According to the data from the statistics in Poland also shows there are 1.9 million diagnosed cases of Poland as much as 50% of adults declare that they wear AMD, including 130,000 cases of the more advanced form glasses or contact lenses to correct distance or near vision of the disease, i.e. wet AMD potentially leading to vision loss defect (in the age group 50–59 it is 76%, and in the age (the risk increasing with age). The major risk factors for AMD

Prof. Krzysztof Korzeniewski, MD, PhD, Chairman of the Polish Society of Maritime, Tropical and Travel Medicine, Powstania Styczniowego St. 98, 81–519 Gdynia, Poland; * Military Institute of Medicine, Head of the Department of Epidemiology and Tropical Medicine, Szaserów St. 128, 04–141 Warszawa, Poland, e-mail: [email protected] 78 www.intmarhealth.pl Krzysztof Korzeniewski, Eye diseases in travelers include smoking, arterial hypertension, high cholesterol have adverse effects on the eye in the longer perspective concentration and obesity. Diabetes mellitus (DM) is one of (dysfunction of the tear film or dysfunction of the secretory the most common chronic diseases in Poland affecting over glands in the eyelid or the conjunctiva) [5]. 2 million people. Chronic hyperglycemia causes damage to the retina and thus plays a major role in the development Dry eye syndrome of diabetic retinopathy. The disease affects approximately It is one of the most common conditions affecting the 90% of patients with type 1 DM and 60% of patients with eye. It usually occurs due to inappropriate or prolonged use type 2 DM who have had the disease for 20 years (diabetic of topical medications for the treatment of conjunctivitis retinopathy is the major cause of vision loss in patients over or blepharitis (inflammation of the eyelid), insufficient tear 65 years old), it also leads to diabetic macular edema. The production or alternations in the quality or quantity of the data from the statistics indicates that there are 4.9 million tear film. The condition is associated with inadequate wet- disabled people living in Poland of whom 35% are affected ting of the cornea and the conjunctiva which causes dis- by an ocular disease or have suffered an eye trauma (over comfort (dry eye sensation, burning, foreign body sensation) 60,000 of Poles over the age of 15 years old have blindness but occasionally may lead to more severe conditions of the or severe visual impairment). In general, the diagnosis of oc- globe. Dry eye syndrome is a disease reflecting the modern ular conditions may be problematic because a large number way of life where much time is spent in poorly-ventilated or of diseases affecting the eye tend to be asymptomatic at an air-conditioned rooms and in front of a computer screen. early stage. In addition, screening for visual defects is rare Under such conditions lacrimal glands do not produce suf- in Poland (around 30% of Polish people have never been ficient tears to compensate for the excessive tear evapora- consulted by an ophthalmologist). With such a high number tion. The major risk factors contributing to the occurrence of patients with visual defects in the general population, it is of the dry eye syndrome during travel include: prolonged not surprising that conditions of the eye are quite common exposure to dry air (in an airplane), difficult weather con- among travelers as well [1–6]. ditions (low humidity, dry wind, dust) exposure to salty or chlorinated water (swimming/bathing in a swimming pool CLINICAL PICTURE or in the sea) [5, 7–9]. The International Classification of Diseases ICD-10 clas- sifies the diseases of the eye and adnexa into 11 categories: Excessive tear production (watery eyes) disorders of eyelid, lacrimal system and orbit; disorders of The condition (often unilateral) may be suggestive of conjunctiva; disorders of sclera, cornea, iris and ciliary body; a blocked tear duct. Acute pain, swelling and redness in the disorders of lens, disorders of choroid and retina; glaucoma; corner of the lower eyelid may be indicative of dacryocystitis disorders of vitreous body and globe; disorders of optic (inflammation of the tear sac). Treatment of a tear drain- nerve and visual pathways; disorders of ocular muscles, age blockage usually requires ophthalmological/surgical binocular movement, accommodation and refraction; visu- intervention [5, 10]. al disturbances and blindness; other disorders of the eye and adnexa. Eye conditions may also arise from injuries, Inflammation of the eye poisoning or congenital disorders; however, those cases Inflammatory lesions affecting the eye are the most are classified outside the category listing the diseases of common ocular conditions. They typically arise from the the eye and adnexa [1]. dysfunction of the glands which are part of the protective A great majority of patients with eye problems are treat- apparatus of the eye (the sebaceous glands of Zeis and the ed on an out-patient basis and the most prevalent conditions sweat glands of Moll in the eyelash follicles, Meibomian include inflammation of the protective apparatus of the eye glands in the tarsal plate of the upper eyelid), the conjunc- or the globe which often manifest with pain, redness, swell- tiva (lining the inside of the eyelid and the sclera) or the ing of the eyelid or the globe or discharge from the conjunc- lacrimal apparatus. The infection often occurs as a result of tival sac. In such cases patients usually complain of foreign a gland blockage (hordeolum, dacryocystitis, abscess of the body sensation, tearing or itching. When visual acuity is not eyelid) or a mechanical injury e.g. contact lens associated decreased, pupils react normally and the cornea is trans- damage to the corneal epithelium (increased susceptibility parent, the symptoms are suggestive of conjunctivitis or to infections). Some inflammatory conditions may be of inflammation of the eyelid. If, however, the symptoms occur endogenous nature (when an infection which has already seasonally, it may be suggestive of an allergic reaction. In affected other organs or systems spreads to the eye). An such cases it is recommended to use antihistamines rather eye infection may subsequently be carried via the angular than antibiotic or corticosteroid drops/ointments. Although vein and the cavernous sinus to the meninges causing they may initially reduce the symptoms, they are likely to neurological disorders [11].

www.intmarhealth.pl 79 Int Marit Health 2020; 71, 1: 78–84

Conjunctivitis. The condition usually affects both eyes lead to the growth disorder, loss or discoloration of the and is the effect of either external (bacteria, viruses, aller- eyelashes [12]. gens) or internal factors. The common signs and symptoms Foreign body in the eye. It is usually a grain of sand, include burning sensation, foreign body sensation, stinging, a speck of dust or a very small insect (e.g. sand fly), its photophobia, tearing, redness and purulent, mucous or presence causes discomfort, tearing, redness and pain. If watery discharge. The condition may be mild to severe patients are unable to remove the foreign body from the with symptoms ranging from slight redness to massive eye on their own, they are recommended to seek medical discharge. Conjunctivitis may be self-limiting and even if it assistance [5]. is left untreated the signs and symptoms usually subside On top of the conditions discussed above, sudden vision within 2 weeks of onset. Nevertheless, patients will benefit impairment may be associated with some systemic diseases from an early diagnosis and prompt treatment as it may help e.g. diabetes, trauma or thrombotic lesions. prevent chronic conjunctivitis or keratitis in the future [11]. Keratitis. The condition usually presents with severe Diabetic retinopathy clinical signs and symptoms (decreased visual acuity, pain, It may happen that an ophthalmologist will be the first photophobia, tearing, discharge, visible corneal infiltrate). physician to diagnose a patient with diabetes (examination Keratitis may be of infectious or non-infectious etiology and of the fundus). This may be the case when a patient reports it may lead to loss of vision. In temperate climate zones to a specialist due to sudden vision impairment, which may keratitis is typically of bacterial etiology, while in the tropical potentially be associated with vitreous or retinal hemor- climate — it is usually caused by a fungal or a mixed infection. rhage. Diabetic macular edema may also be responsible In patients wearing contact lenses inflammatory lesions for sudden vision impairment in diabetic patients; mild (resulting from damage to the corneal surface) are usually diabetic macular edema may be associated with slightly associated with Pseudomonas aeruginosa infection. The decreased visual acuity, whereas its severe form may lead common risk factors for keratitis include bacterial or viral to vision loss [4]. infections of the eye surface, injuries, diabetes, and immu- nosuppressive treatment. Inflammation manifesting with Retinal vascular occlusions tissue loss and corneal infiltrates may lead to scarring and The condition usually occurs in the elderly patients with perforation of the cornea and eventually to loss of vision [11]. a history of atherosclerosis, diabetes, or arterial hypertension Orbital cellulitis. It is commonly caused by the spread but may also be found in women at the childbearing age using of an infection from the paranasal sinuses but it may also hormonal contraceptives. The central retinal vein occlusion occur as a complication after a sinus or ocular surgery. The (CRVO) results in sudden vision impairment and requires condition is serious (the risk of a generalized infection) and immediate hospital treatment, whereas a branch retinal requires treatment on an in-patient basis [12]. vein occlusion (BRVO) is a mild condition which may give no Hordeolum. It is an infection of the eyelid glands (glands symptoms and may go unnoticed. In most cases both the of Zeis, Moll or meibomian glands), which is usually caused CRVO and BRVO are unilateral [4, 13]. by Staphylococcus aureus. Hordeolum may be either external or internal; the former results from obstruction and Retinal hemorrhage infection of an eyelash follicle and adjacent glands of Zeis It is a disorder of the retina which commonly occurs at or glands of Moll, while an internal hordeolum, results from high altitudes, e.g. during high altitude climbing. Exposure to an infection of a meibomian gland (tarsal glands), which is hypobaric hypoxia increases retinal blood flow and leads to responsible for the production of the tear film lipid layer [12]. retinal hemorrhages (the retina is highly sensitive to hypoxic Chalazion. It is a chronic infection of a meibomian gland conditions). The condition is often asymptomatic, but may caused by obstruction of the gland and accumulation of sometimes be associated with visual disturbances (seeing lipid material in the eyelid leading to the formation of a cyst floaters or flashes of light, blurred vision, decreased acuity) usually associated with redness and swelling. If a chalazion due to bleeding at or around the macula. Retinal hemor- persists for more than several weeks despite treatment rhage was found to occur in approximately 30% of climbers (topical antibiotic and hot compresses), the recommended who reach the altitude of 4200 m a.s.l., 50–60% of climbers treatment of choice remains incision and curettage [12]. at 5500 m a.s.l., and supposedly in 100% climbers at 6800 Blepharitis. It is a bilateral chronic infection of the eyelid m. a.s.l. If retinal hemorrhage occurs, the ophthalmologic causing irritation of the eye and burning sensation. It is examination will reveal optic disc hyperemia and increased often associated with conjunctivitis, keratitis, formation vessel tortuosity in the fundus of the eye. In most cases the of intrafollicular abscesses at the base of the eyelashes condition is self-limiting and retinal bleeding usually stops and disruption of tear secretion. Chronic blepharitis may after 1–2 weeks [14].

80 www.intmarhealth.pl Krzysztof Korzeniewski, Eye diseases in travelers

Retinal detachment es or contact lenses, all the regularly taken and emergency The disorder is clinically silent and often unilateral. It medications as well as products for eye care (drops and leads to sudden visual impairment; it usually affects the wipes). If, nevertheless, eye or vision problems do occur elderly patients with advanced myopia. In younger patients during travel, the traveler will have to assess the nature of retinal detachment is most commonly trauma-related (the the condition and its severity. If the lesions are associated eye or head injury). Patients with retinal detachment report with exposure to external or environmental factors and the a decrease in the field of vision. If the macula is not involved, condition is mild enough to be managed individually with central vision may be preserved; however, if the macula is the available medications, there is no need to seek medical involved, the prognosis is much worse and lesions may be help. If, however, the lesions are more severe, travelers are irreversible. Retinal detachment is an emergency condition strongly recommended to report to a medical facility for and requires immediate surgical intervention [4]. a consultation with an ophthalmologist (eye examination, specialist treatment). In order to establish an accurate diag- Eye trauma nosis, an ophthalmologist must have access to the specialist An injury to the eye may be the result of a traffic accident ophthalmic diagnostic equipment (an ophthalmoscope for as well as a sports injury or even UV radiation. It is strongly the fundus examination, a slit lamp to inspect the anterior recommended that all travelers, both children and adults segment of the eye/eyelids, conjunctiva, sclera, iris, lens, wear certified sunglasses for UV protection [15]. cornea/, tonometer to determine the intraocular pressure, etc.) [22]. The type of treatment will depend on the condition DISEASES OF THE EYE IN HOT itself, the outcome of the clinical examination as well as the CLIMATE CONDITIONS results of diagnostic tests. Intraocular and orbital infections Travelers to tropical or subtropical destinations, with of bacterial etiology require the use of systemic antibiotic high prevalence of pathogens or infection vectors which are therapy and the parenteral administration of antimicrobial specific for the hot climate areas, may develop diseases of agents. Post-traumatic or post-surgical anterior uveitis is the eye which are rarely seen in temperate climate condi- managed with subconjunctival injections (the drug admin- tions. Such conditions include visual impairment character- istered in this way reaches the iris, the ciliary body and the istic for onchocerciasis (Onchocerca volvulus microfilariae cornea through the sclera route). In case of an intraocular migrate from the skin into the conjunctiva, cornea and inflammation, the drug is injected into the anterior cham- anterior chamber of the eye leading to keratitis, anterior and ber or the vitreous humor. Topical medications (e.g. drops, intermediate uveitis (inflammation of the iris and the ciliary suspensions and ointments) are used for the treatment body) and eventually to vision loss); conjunctivitis/foreign of infections/inflammation of the anterior segment of the body in the eye in loiasis (Loa loa microfilariae penetrate into eye (strict compliance with hygiene recommendations is the subconjuntival tissues), swelling of the eyelid and con- essential in such cases). The drugs administered into the junctiva in gnatostomosis, swelling of the eyelids in African conjunctival sac are absorbed through the cornea (topical trypanosomosis, or conjunctivitis and keratitis in trachoma. medications may enter into the systemic circulation via the Of all the eye conditions seen in travelers to tropical or sub- highly vascularized conjunctiva and further via the lacrimal tropical destinations conjunctivitis is the most common; in sac and may potentially cause adverse reactions; therefore, such cases conjunctivitis is either of cosmopolitan (bacterial patients must strictly comply with the recommended dosage or viral infections, allergic inflammation) or tropical e.g. regimens and respect the expiry date and the period after arboviral infections (zika, chikungunya) etiology [16–21]. opening) [8, 12, 22, 23].

TREATMENT PREVENTION The treatment of any diseases of the eye (e.g. decreased In general, travelers are likely to be exposed to a num- visual acuity, acute or chronic inflammatory conditions, ber of risk factors which may result in the manifestation degenerative lesions or eye trauma) requires consultation of acute eye conditions or the exacerbation of underlying with an ophthalmologist. This must be remembered by all ophthalmological diseases. The most common risk factors travelers but especially those travelling to countries where which cause irritation (dry eyes, burning sensation, redness) specialist healthcare is unavailable or difficult to access (a of the eye or its protective apparatus include prolonged professionally equipped office of an ophthalmologist vs. exposure to air-conditioning (inside an airplane cabin or in a primary health care provider in remote areas of Asia or a hotel room), wind, low humidity, chlorinated water in the Africa). Therefore, it is recommended that travelers with swimming pool or salty water in the sea. If the eyes feel dry underlying eye conditions take good preparations before or irritated, travelers may use re-wetting eye drops. Artificial going on a journey. They must not forget to bring their glass- tears may be used both for prevention and treatment of

www.intmarhealth.pl 81 Int Marit Health 2020; 71, 1: 78–84 the dry eyes symptoms. A good way to stabilize the lipid sion. Category 1 (43–80% transmission) or Category 2 are layer of the tear film and prevent its evaporation is to use recommended on cloudy days (sun radiation is lower but still eye drops containing sodium hyaluronate. The drops lu- present), Category 3 (typical for most types of sunglasses) bricate the corneal surface and may be used with all types is recommended on sunny days, this category is also rec- of contact lenses. Moisturizing eye drops are also recom- ommended to drivers (drivers are suggested to wear sun- mended to patients with certain chronic conditions such as glasses with polarized lenses which additionally eliminate Sjögren’s syndrome, hormonal imbalance (menopause) or the glare). Category 4 sunglasses (3–8% transmission) are patients with a history of an ophthalmologic surgery [24, 25]. recommended to be worn in intense sunshine e.g. in snow Travelers who are likely to be exposed to difficult climate covered mountains; they are not to be used while driving conditions (high temperatures, humidity, air pollution) are as the lens are too dark. Travelers need to keep in mind recommended to take good care not only of the eyes but that sunglasses which are sold in the developing countries also of their protective apparatus. A good solution is to use may be of low quality. Therefore, before buying a pair of sterile eyelid wipes (e.g. Blephaclean) for everyday hygiene sunglasses abroad it is important to check whether the lens of the eyelashes and eyelids. The wipes show antibacterial, have been certified (those which meet the requirements will anti-inflammatory and regenerative effect and can also be be marked as follows: EN 166:2001, PN-EN ISO 12312- used for make-up removal [22]. 1:2014-02, 89/686/EWG, ISO 9001:2000) [22, 29–32].

Dry eye syndrome Travelling with contact lenses Artificial tear drops are the first line treatment for pa- Given the fact that a considerable proportion of travelers tients with dry eye symptoms (the medication is short-acting have decreased visual acuity and many are contact-lens and should be applied at regular intervals, several times wearers, it seems reasonable to discuss some general a day; artificial tear drops should be free from preservatives guidelines for travelling with contact lenses. First, contact as they may irritate the eye). Apart from using the right med- lens wearers are strongly recommended to bring not only ications, one should also remember about some simple pre- their contact lenses but also a pair of glasses as a back-up. ventive measures to reduce tear film evaporation (wearing Wearing glasses may be more comfortable then wearing large frame glasses which provide better protection from the contacts in some situations, e.g. during a long flight last- wind, dust or the sun; placing the computer screen below the ing 6–8 hours or more. Low humidity inside an airplane is eye level to narrow the eye opening; trying to reduce smoking primarily the effect of the air conditioning but also of high and avoiding smoke-filled rooms, using rewetting eye drops altitude conditions (the cabin pressure corresponds to an al- while staying or working in air-conditioned rooms) [26–28]. titude of 1800–2400 m a.s.l.). What is more, sleeping on the plane will be much more comfortable with lenses removed. Sunglasses Another common problem for contact lens wearers is the Sunglasses are an essential travel item, especially when exposure to dry air (e.g. an air conditioned hotel room). Dry travelling to areas where UV exposure is high. The most air may cause discomfort and irritation so it is very important important sunglasses component is obviously the UV fil- to keep your eyes moisturized by using rewetting drops/ ter. When a person wears darkened glasses, pupils dilate /artificial tear drops or by wearing moisturized lenses. When because less light reaches the eye; therefore, wearing sun- travelling to sunny destinations (the seaside beach, high glasses without a UV filter actually increases the exposure mountains, a skiing holiday), contact lens wearers must not to UV radiation as more sunlight enters the eye through forget about adequate UV protection. Some manufacturers dilated pupils. Excessive UV radiation may cause damage are now marketing contact lenses which block the UV radia- to the cornea, lens or retina. Travelers with a vision defect tion and thus provide protection against the harmful effects are recommended to wear both their contact lenses and of the sun [33]. Also, travelers who wear contact lenses need sunglasses with a UV filter. If, for some reason, travelers to take certain precautions when swimming in the pool or in cannot wear contact lenses (inflammatory lesions, swim- the sea. The best solution is to avoid wearing contact lenses ming/bathing in the water) they are advised to purchase in the water. This is because contact lenses increase the risk darkened prescription glasses or glasses with photochromic of infection with the pathogenic microorganisms which may lenses (darkening when exposed to the sun). Sunglasses be present in the water. Although generally not harmful to which provide protection against the UV radiation should the skin, the respiratory or the gastrointestinal system, some be labeled (on the lens or frames) as ‘UV400’, ‘100% UV pathogens which are found in the water (Acanthoamoeba reduction’, ‘100% block’ or ‘UV 100%’. In line with current protozoa) may contaminate the lens and consequently lead recommendations, the UV protection filters fall into four to corneal inflammation [34]. Travelers must also remember distinct categories, depending on the level of UV transmis- to follow the contact lens hygiene recommendations (this

82 www.intmarhealth.pl Krzysztof Korzeniewski, Eye diseases in travelers

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TROPICAL MEDICINE TROPICAL article Review Krzysztof Korzeniewski ...... in travelers diseases Eye Safety behaviour and healthy diving: a qualitative qualitative diving: a healthy and behaviour Safety study fishermen diverse in the traditional of citations of maritime Follow-up injuryepidemiological studies...... Original article Kusnanto Kusnanto, La Rakhmat Wabula, Bambang Purwanto, Hidayat Arifin, Yulia Kurniawati MEDICINE IN MARITIME DEVELOPMENT article Review Baygi, Olaf Chresten Jensen, Agnes Flores, Fereshteh Despena Andrioti Bygvraa, George Charalambous HYPERBARIC MEDICINE Original article Richard Pougnet, Laurence Pougnet, Jean-Dominique Dewitte, Brice Loddé, David Lucas of unfitness permanent and Temporary Brest divers. occupational Cohort 2002–2019 Network National French from the Vigilance Disease Occupational for ...... (RNV3P) Prevention and Case report Sikka, Nicholas Page, Keith S. Boniface, Neal Asi Peretz, Hamid Shokoohi evacuation medical emergency ship A cruise findings ultrasound handheld by triggered tele-ultrasound by directed and MEDICINE MARITIME/OCCUPATIONAL Original article Anja Leppin Solveig Boeggild Dohrmann, Kimmo Herttua, work psychological and physical Is in stress fatigue with associated ...... ferryDanish employees? ship MARITIME MEDICINE EDUCATION 9 5 1 4 10 34 20 28 12 ...... CONTENTS